IDPH has cited and fined The Mooring nursing home in Arlington Heights after a resident there choked to death. Topping that off, when the state inspectors were at the facility a month and half later, the same systems failures were evident for other residents who were at risk of choking.
Nursing homes are businesses, and well-run businesses have systems in place to deliver the basic services that they are supposed to provide. In a nursing home setting, that is the care that is needed to provide for the safety and well-being of the residents. Sometimes those systems are the nursing home’s internal policies and procedures; other times, those services are delivered through the care-planning process. Either way, the care that needs to be delivered on day-to-day, shift-to-shift basis needs to have some system in place to ensure that the care is in fact delivered.
What is not acceptable is to have care that is crucial for the safety and well-being of residents provided on a catch-as-catch-can basis. Sadly, that is what was occurring at The Moorings, and this resulted in the wrongful death of one nursing home resident.
The resident at issue had a physician order for thin liquids. This is usually ordered for residents who have swallow difficulties. She also required supervision with the assistance of one while eating. Earlier on the day of the choking accident, the resident was observed by an aide to be coughing and choking while drinking water. The aide reported this to a nurse and the speech therapist. One of the main functions of the speech therapist in a nursing home is to address a resident’s risk of choking by making dietary recommendations and offering services to reduce the risk of choking.
The usual practice for this speech therapist would be to downgrade the resident’s diet order to a different consistency intended to reduce the risk of choking. However, the speech therapist told the surveyor that was not done and said that it should have been done. She also said that she did not speak to the nurse assigned to the resident before leaving work that day. The speech therapist also explained that at this nursing home there was no system for informing staff who is at risk for choking other than word-of-mouth communication. She explained that the meal tickets show what kind of diet the resident is on, but do not identify which residents are at risk of choking or what strategies should be employed to reduce the risk of choking.
Later that night, she was eating dinner when she began to choke. Her husband yelled for help. The staff came, attempted the Heimlich, but that was not effective. She lost consciousness and was taken to the hospital where she died 5 weeks later of complications related to the choking accident.
The state surveyor also interviewed other staff members. One aide described having witnessed a choking incident a week earlier and having told the nurses about it. The other three staff members (one aide, two nurses) all denied know that she had a history of choking or of needing any supervision or assistance with eating.
The death of this nursing home resident is the very definition of catch-as-catch-can nursing, and is a formula for disaster. Here is a resident who obviously had some swallow difficulty (hence the order for thin liquids) and had a specifically observed episode of choking observed, but there is no care planning done to address that risk. The whole point of the care planning process is to identify risks to the health and well-being of the resident and to identify measures that can be taken to address that risk. Instead of taking a series of systematic routinized steps to keep a resident safe, it was left to word of mouth and the judgment of the nurses and staff that particular day. In short, necessary care is being delivered by random chance, and that is a formula for failure.
Having sustained a fatal choking accident, one would hope that this would spur the nursing home administration to change their approach to residents who are risk of choking. Unfortunately, the state surveyor found otherwise. One resident with a history of Parkinson’s Disease and stroke, both of which can cause swallow problems and contribute to choking risk and had a swallow study done which showed he was at high risk for choking. He was observed eating unsupervised and unattended. Another resident with a history of dementia, stroke, and a diagnosis of dysphagia (swallowing disorder), and a prior choking incident was observed eating in a large dining room but the aides there were unaware that the resident was at risk for choking.
The failure of this nursing home to change how it addresses choking risk after a fatal choking accident is dumbfounding, but doing do is the kind of thing that requires attention and focus. Nursing homes have that in short supply because of how they operate. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
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