IDPH has cited and fined Sunset Rehabilitation & Health Care nursing home in Canton after a resident there choked to death while eating lunch.
The resident at issue here had a history of having had a traumatic brain injury. One way in which this manifested itself was in behavior disturbances which manifested itself by eating very rapidly, not chewing, and walking around while eating. These behaviors placed the resident at risk for choking.
When a resident is at risk for harm, it is incumbent on the nursing staff to develop a care plan outlines a series of steps which are to be taken on a day-to-day, shift-to-shift basis to prevent the harm from occurring. It also recommended that he be given “finger foods” to eat. In this case, the steps incorporated into the resident care plan was to provide one person assistance with eating – a level of care which was also documented on the resident’s Minimum Data Set (MDS).
On the day of this nursing home choking accident, the resident was given a slice of ham, sweet potatoes, and a vegetable to eat. He got up from the table while still eating and began to choke, collapsing in a nearby hallway. The staff attempted to clear the airway and perform CPR, but the resident died before he could be brought to the hospital. Cause of death was brain hypoxia, or loss of oxygen to the brain.
IDPH’s investigation of the incident uncovered a number of troubling findings:
- Even though the use of finger foods was a part of the resident’s care to address his risk of choking, there was no diet order to that effect. In fact on the day that he died, he was served ham and sweet potatoes – things that can hardly be characterized as finger foods. Further the ham was not cut into smaller pieces to mitigate the risk of choking. The facility cook stated that he was not aware of the resident’s care plan and never looked at resident care plans.
- The resident’s care plan called for one person assistance with eating while he was only receiving supervision that day. The difference between the two is getting some physical help versus cues and reminders to slow down while eating. The net difference here was that there was no one to cut his food into smaller pieces which very easily could have been the difference between having a fatal choking accident and surviving this event.
- Many of the staff had expired CRP certifications, including several of the staff members who responded to the emergency. Beyond having expired certifications, the ambu-bag (a device which uses a bag to force air into the lungs during CPR) was never employed until the paramedics arrived, the staff did not know how to determine the resident’s code status, or whether CPR should be attempted on a resident who is DNR (it should).
This is a classic example of a situation where the nursing has failed the resident for a long period of time, but avoided catastrophe only by sheer luck. Good luck is not a substitute for good care. The resident had a care plan which did not correlate with the diet orders, the process by which that care plan would be implemented (having the kitchen prepare meals which complied with the car plan) didn’t work because the kitchen staff didn’t review care plans, and the staff was ill-trained and without required certifications. This is an accident which could have occurred to any number of residents on any number of days.
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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