IDPH has cited and fined Alden Poplar Creek nursing home in Hoffman Estates after a fatal choking accident involving one of the residents.
There a number of conditions which can place a nursing home at risk for choking. Among these are difficulty with swallowing (known as dysphagia), dementia, poor dentition, Parkinson’s disease, and a number of other neuromuscular disorders. A resident’s risk of choking can be evaluated by a speech therapist in a clinical setting or the resident can be sent to a hospital for a video swallow study.
However a resident is determined to be at risk of choking, once that determination is made, that risk must be addressed in the resident care plan. One thing that a speech therapist does is assess deficits in the resident’s swallowing function and then recommends various strategies to minimize the risk of choking. Often these will take the form of a modified diet and supervision at meals. These recommendations should be tailored to the particular needs of the resident and should be incorporated directly into the resident care plan so that all of the staff charged with caring for the resident know what steps should be taken to keep the resident safe.
Here, the resident was at risk for choking. He had been diagnosed with dysphagia, Parkinson’s, and dementia. The resident had a video swallow study done at the hospital after a prior choking episode. This confirmed that the resident had swallowing difficulties. When he returned to the nursing home, the speech therapist made a number of specific recommendations regarding the resident’s eating which were intended to address the risk of choking. These included: one-to-one supervision during meals and cuing the resident to take sips of water in between bites because due to the Parkinson’s, he often did not swallow all of the food in his mouth on the first effort. The resident’s care plan addressed the risk of choking, but did not include all of the recommendations made by the speech therapist.
On the day of this nursing home choking accident, the resident was seated in a small dining room in the memory care unit. He had finished eating but the tray was left in front of him with food still on the tray, as well as some food his family had brought to the facility for him to eat. The staff in the dining room were all attending to other residents. The aides heard a gurgling sound coming from the resident and brought the nurse in. The nurse attempted the Heimlich, but could not clear the airway and lowered the resident to the floor. A nurse practitioner and a doctor who happened to be in the building came to assist with resuscitation efforts. After paramedics arrived, they intubated the resident but were unable to revive him. He was pronounced dead at the nursing home. Cause of death was asphyxia due to choking on a food bolus.
There were a number of issues with the care that this resident received which contributed to his death. First, the care plan failed to include the recommendations made by the speech therapist. The whole point of having a speech therapist make recommendations is to find out what has to be done to assure the safety of the resident. If those recommendations are not incorporated into the care plan to be carried out on a day-to-day, shit-to-shift basis, then the recommendations have no real value. One of the crucial recommendations that was made is that the resident needed one-to-one supervision while eating, and if a resident is left with a food tray and other food in front of him, then there is a risk due to the resident’s dementia that they will go ahead and continue eating with no supervision. That is what occurred here.
Second, the staff left the resident’s tray in front of him thinking that he was done eating. This is contrary to what the speech therapist said needed to be done, as well as the facility’s own policies and procedures. Had these procedures and recommendations been followed, this resident would not have died in this manner.
Having staff that is unaware of the facility’s own policies and procedures is a mark of poor training. Nursing homes are businesses and well-run businesses have policies and procedures (“this is how we do things here”) that tell them how to deliver the basic services that the business provides, and the staff must be trained on them. Without training of the staff, good policies do nothing more than fill binders on a shelf, and nursing home residents deserve better than that.
Sadly, having a poorly trained staff is entirely consistent with now most nursing homes operate, because training staff costs money and that cuts into profits. 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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