IDPH has cited and fined Hillcrest Retirement Village in Round Lake Beach after a resident suffered two choking incidents over a three day period with the final one resulting in the death of the resident.
The resident was readmitted to the facility after being hospitalized due to aspiration pneumonia. Aspiration pneumonia occurs when something (commonly food) enters the lungs and causes an infection. People who have difficulties with swallowing often experience aspiration pneumonia because the swallow process for them is disorganized and as a result they end up having food particles enter the lungs, resulting in the infection. When the resident was readmitted to the facility, he was noted to have diagnoses of dementia and dysphagia (swallowing difficulty) and his care plan included monitoring for signs and symptoms of choking, coughing, and pocketing of food while eating. His diet order was for pureed foods and honey thickened liquids. This diet order was intended to reduce the risk of choking.
Additionally, he underwent three weeks of speech therapy. One of the important tasks that a speech therapist handles in a nursing home setting is treating residents with swallowing difficulties and making recommendations regarding diet orders. While many nursing home residents would prefer to eat as normal a diet as possible, getting a proper diet recommendation from a speech therapist is a key measure in reducing the risk of a nursing home choking accident. After the three weeks of speech therapy, the speech therapist recommended that the resident’s diet be upgraded to a general diet with no restrictions, and the resident’s doctor entered the order.
Two days after the resident’s diet was upgraded, he experienced his first choking incident. He was eating dinner when his face began to turn blue. One of the aides working in the dining room gave him back blows, and this was sufficient to expel some of the fish and bread he was choking on, and the staff was able to reach into his mouth and clear the remaining food away.
The nurse on duty at the time of the first choking accident noted the occurrence on the resident’s chart. However, she never notified the resident’s doctor or the speech therapist that there had been a choking incident. Both the doctor and the speech therapist told the state surveyor that had they been notified of this choking incident, they would have downgraded the resident’s diet to include foods with a consistency that poised a lower choking risk. The facility’s policies and procedures also permitted members of the nursing staff to downgrade a resident’s diet if there were safety concerns. However, the nurse was apparently unaware of that and believed that simply documenting the fact that a choking accident had occurred was enough.
Sadly, it wasn’t.
Three days later, the resident was eating dinner again, with the unchanged general diet order – despite the choking incident just a few days earlier. The resident again choked on food, but this time, lost consciousness and became pulseless and unresponsive. Paramedics were called and CPR was performed. The paramedics attempted intubation, but they were unable to place the tube due to the airway being obstructed by food. The resident was brought to the hospital where he died two days later.
Care in a nursing home setting is often looked at as being provided by an interdisciplinary team which obviously includes the nursing staff, but also includes professionals such as the speech therapist and the resident’s doctor. This is the kind of tragic outcome that results when the members of the team do not communicate with one another. It was the job of the nurse to let speech therapy and the doctor know about the incident, and both stated that they would have downgraded the resident’s diet, but they never were given the chance to do so. This is also the kind of outcome that results from a member of the nursing staff failing to appreciate the hazard that a choking incident represents and failing to know what tools were available to her to address that hazard. The nurse had the ability to downgrade the diet independent of the doctor and speech therapy. Given the opportunity to prevent this outcome by 1) notifying the doctor, 2) notifying speech therapy, and 3) acting independently to downgrade the diet, she did nothing, and the wrongful death of this resident was the result.
While a heavy dose of fault lies on the nursing staff, the role of the speech therapist also deserves careful consideration. It was the decision of the speech therapist to upgrade the resident from a puree diet to a general diet which set the stage for this outcome, and that decision deserves special scrutiny. It is important that this is done at the outset of any case because speech therapists are generally not direct employees of a nursing home, but are independent contractors.
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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