IDPH has cited and fined Iona Glos Specialized Living Center in Addison, Illinois after a fatal choking accident involving a resident there.
Iona Glos is a facility that primarily serves adults with developmental disabilities. The resident at issue had devlopmental delays which manifested itself in part by the resident “shoveling” food into his mouth while eating. His diet included only soft or ground meat, soft moist bread with no crusts, and soft vegetables. He also a mealtime protocol (a care plan) which was designed to help him eat safely by providing monitoring during mealtimes with cueing and prompting to eat slowly and to swallow before taking another bite.
On the morning of the accident, the resident was being served oatmeal and banana bread in the dining room. There was an aide in the room who had worked the overnight shift and was assisting another resident. The aide was not watching the resident at issue eat and did not know what the mealtime protocol for the resident was. He did not see the resident eat the three by four inch piece of banana bread because he was not watching.
Suddenly, the resident got up from the table and hurried to the bathroom. The aide followed him into the bathroom because the resident was known to play with feces in the toilet and he did not want the resident to get his outfit dirty for a planned family visit. The resident suddenly fell to the floor without hitting his head. The resident was unresponsive, so the aide called nurses over to assist, but did not initiate CPR or check his airway because he was concerned about a head or neck injury and because the resident did not give off any sign of choking such as gagging or coughing.
When the nurse arrived, she began CPR and noticed that there was something mushy in his mouth and attempted to clear the airway. Police arrived shortly thereafter and attempted abdominal thrusts. Finally, the paramedics arrived and cleared the airway with forceps and was able to intubate him. Despite vigorous efforts at resuscitation, the resident died that afternoon.
The nursing home here had done a reasonable job under the circumstances of identifying the issues and coming up for a care plan to avoid a nursing home choking accident. The resident had been properly identified as being at risk for choking by virtue of his known behavior of shoveling food into his mouth (which is a relatively common behavior in nursing home residents with some forms of mental illness or dementia). There was also a reasonable plan in place: keeping him under observation during mealtimes and cuing him to eat in a safe manner.
The problem here came from the fact that the aide who was there when the accident happened didn’t know that was what the plan was. When a care plan is put into place, it is up to the nursing home staff to carry out the care plan on a day-to-day, shift-to-shift basis. There are some items in care plans which if neglected once may not have catastrophic events (such as with bed sores), but there are other such as with choking or nursing home falls which can have truly catastrophic conseuqences if the care plan is neglected even once. In order for the direct care staff to do that, the care plan must be communicated to them. This aide simply did not know what the care plan for this resident was and as a consequence, the resident stuffed a whole piece of banana bread down his throat, resulting in the wrongful death of this nursing home resident.
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