IDPH has cited and fined AHVA Care of Winfield nursing home after a resident there choked to death on a peanut butter sandwich.
The risk of choking on food is a risk that residents in nursing homes are often at increased risk for as compared to the general population. There are a handful of factors which may play into that. Key risk factors that contribute to this may include (1) physiologic factors – there may be issues with chewing, or otherwise breaking the food up for safe eating or impairments to the actual swallow function from neurologic or muscular dysfunction, (2) behavioral – residents may eat too rapidly, overstuff their mouths, or have a compulsion to eat things which are not theirs or not safe for them to consume, or (3) dementia – this may cause people to eat inattentively so that they end up trying to swallow things that are not safe for consumption.
When a resident is at risk for choking this must be addressed during the care planning process, often with the help of a speech therapist. There are six basic steps with the care planning process: : (1) a resident assessment where the risks to the health and well-being of the resident are identified, (2) the development of a care plan which identifies steps or interventions to be taken to address the risks to the resident and assigns various staff to carry out those steps, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) evaluation of the effective of the care plan on an ongoing basis, and (6) revision of the care plan if the resident’s needs change or if the care plan proves to be in ineffective in practice.
The resident here had a number of diagnoses, including a traumatic brain injury and dry mouth. His care plan stated that he at time would overstuff his mouth with food. One of the identified measures intended to address that was to have the resident take small bites. However, the resident was not added to the list of resident with swallowing difficulties or at risk for choking.
On the night of this nursing home choking accident, the resident came out of his room at approximately 3:00 a.m. He went to the nurses station and asked for a peanut butter sandwich. He sat on a chair by the nurse’s station and one of the nurses saw him take an enormous bite of the sandwich – she told the state surveyor that it was almost half the sandwich. When he was done eating, he began walking back to his room. The nurses noticed that he was walking unusually, and stopped and sat down in a chair in the hallway outside his room. After he sat down, he fell from the chair.
The nurses rushed over and saw that he was not breathing. They saw food particles in his mouth and lips and realized that he was choking. They attempted to resuscitate him by sweeping his mouth and doing the Heimlich maneuver, but that failed to clear his airway. Paramedics were called. When they arrived, there was no heart beat. They placed an endotracheal tube, but efforts to revive him were unsuccessful and he was declared deceased. When the tube was removed, there was peanut butter on it. Cause of death per the coroner was choking on peanut butter.
Here, there was a basic breakdown of the care planning process. This resident had been assessed as being someone who overstuffed his mouth – a behavioral risk for choking. This was addressed in the resident care plan. However, the nurses on duty were apparently unaware of this risk or the steps that had been outlined in the care plan itself, as they watched him consume half the sandwich in a single bite. Further, the resident was not on the list of residents who had swallow issues or were at risk for aspiration/choking, denying the nurses an easy way to identify him as a choking risk.
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.
Other blog posts of interest:
Resident at Aspen Rehab in Silvis chokes to death due to violation of care plan
Winston Manor resident chokes to death on peanut butter sandwich
Resident chokes to death at Warren Barr North Shore
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