IDPH has cited Aperion of Spring Valley Nursing Home after a resident there choked to death while eating. Sadly this was the second fatal choking accident at that nursing home in the last two years.
In the earlier choking incident, the resident was given food which was not consistent with her dietary restrictions. She was not being supervised while eating, even those this was called for in her care plan because she was not able to eat safely due to her dementia and diagnosed dysphagia, or difficulty with swallowing. Sadly, the nursing home failed to learn or apply some of the lessons that should have been learned from this earlier fatality.
The resident involved in this incident had a number of diagnoses that would have placed him at risk of choking. First, he suffered from dysphagia, or difficulty in swallowing. He also suffered from dementia, intellectual disability, postural kyphosis (hunching of the back). When someone has diagnoses which place them at risk for choking, they are customarily referred to speech therapy, who evaluates the resident’s risk of choking and makes diet and other recommendations intended to minimize the risk of choking.
Here, the resident was in fact seen by speech therapy who determined that the resident was at risk for choking and was given a diet of mechanical soft foods with nectar thickened liquids. The recommendations also included one for constant supervision. This was backed up by physician order which in addition to the diet restrictions, also called for giving no more than a ounce of fluid at one time due to impulsivity, take small bites of food and small sips of liquid due to dysphagia, have the resident drink liquids after 2-3 bites of food.
The care planning process is a multi-step process by which risks to the health and well-being of the resident are addressed. These steps include: (1) assessing the risks to the health and well-being of the resident, (2) developing a care plan which reduces to writing the steps which must be taken to address those risks, (3) communicating the care plan to the staff members charged with carrying it out, (4) actually implementing the care plan, (5) evaluating the effectiveness of the care plan, and (6) revising the care plan if it proves to be ineffective in practice or the care needs of the resident change.
When a speech therapist issues recommendations for safe eating or a physician issues standing orders regarding diet, these are customarily included in the resident care plan. However, these were not included in the care plan for this resident.
Why? The director of nursing told the state surveyor who investigated this incident that she did not know that diets should be included in the care plan. As a result, the steps which should have been taken to keep this resident safe were not communicated to the staff.
Despite this, the staff was aware of the need for supervising the resident. They were aware that the resident would try to eat too quickly and shove more food into his mouth than was safe (something that is fairly common among nursing home residents suffering from dementia). They knew that he needed cueing to slow down and to drink water and that at times he would need assistance with the eating. They also knew that he should not be left unattended his meal tray.
On the day of this fatal nursing home choking accident, the resident was brought to lunch and seated at a feeder table with aide. The residents were being feed ground beef stew, biscuits, soft cooked vegetables, cake, and a beverage. These are items which are consistent with the mechanical soft diet.
While the residents were being lunch, the aide at the table was called out of the dining room to deal with a crisis with another resident. When she left the dining room, the tray with the food was left with the resident. There was no one supervising the resident.
Less then 5 minutes later, a family member of another resident saw that the resident was choking and yelled out that this was happening. Other staff responded and pulled the resident away from the dining room in his wheelchair. Staff at first attempted to perform the Heimlich maneuver with the resident still in the chair, but this was unsuccessful, so the resident was removed from the chair and placed on the floor. A nurse attempted to clear the resident’s airway with a finger sweep, but was only able to remove a small potion of the biscuit.
The crash cart was brought to the resident, but where he was placed on the floor was far enough away from an outlet that the suctioning device could not be plugged in, so maintenance had to be called to bring an extension cord.
In the interim, 911 had been called, and the paramedics arrived. When they arrived, the staff was still trying to clear the airway. They used a suction device and forceps and were able to remove more biscuit from the resident’s airway. However, by the time that the resident’s airway was cleared the resident had lost his pulse. There was a DNR in place, so the paramedics inquired of the hospital whether they should continue resuscitative efforts. They were instructed to continue to do compressions and bring the resident to the emergency room. However, once they arrived, the staff there determined that the resident could not be treated in a manner consistent with the DNR, so efforts were stopped and the resident was pronounced dead.
During its investigation, IDPH determined that only one nurse was in the building who had a current CPR certification, and she was not involved in the care of this resident because she was assigned to work the COVID wing of the building. The aides involved were not certified, either. This was despite a facility-wide policy requiring all staff to have current CPR certifications. The director of nursing explained to the state surveyor that there had been changes in the human resources department and the certifications were not being tracked.
The key issue here is that the resident was not being supervised while eating despite a well-recognized need for doing so. The resident was left unattended with his meal tray while the aide left to help elsewhere. While this was going on the resident ate too much biscuit too quickly (a behavior which was well-known to the staff) which he was not able to swallow because of his dysphagia. The aide simply should not have left him unattended and with his meal tray. If helping with the other resident was absolutely necessary, then the tray should have been taken out of the reach of the resident. Instead, he was left unattended to the point that it fell to a visiting family to recognize that the resident was choking.
After one previous fatal choking accident, the nursing home should have learned a hard lesson about failing to supervise residents who were at risk of choking, but that lesson was not absorbed. Sadly, failing to learn hard lessons seems to be too often true in the long-term care industry. 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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