IDPH has cited and fined Glenwood Healthcare & Rehab after a resident there choked to death despite being on aspiration precautions. Incredibly, this is the second choking incident at Glenwood in a year where the nursing home has been cited and fined by IDPH.
One of the base level commitments that nursing homes make to families of the residents admitted to the facility is that we will do the things that are necessary to keep your loved one safe. In turn, families place their trust in the nursing home and its staff to do just that. At times, that trust is broken in the most egregious way. This incident is one of those times.
The resident at issue had been a long term resident of the nursing home apparently due to a brain injury which left his with hemiplegia (weakness on one side) and difficulty with swallowing. On June 11, 2018, he had a choking incident where the staff recognized that he was choking, did the Heimlich menuver, and had him sent to the hospital, where he was admitted for nine days for treatment of aspiration pneumonia (pneumonia caused by foreign objects such as food entering the lungs).
Following his return to the nursing home, there was a physician order for aspiration precautions, and he was referred to speech therapy. One of the things that speech therapists do is work with people who have difficulty with their swallow function. After the completion of speech therapy, he remained on aspiration precautions. He was assessed as needing one-on-one assistance with feeding. At this facility, residents who are on aspiration precations should be brought to the dining room (where they are likely seated at a feeder table) or are fed one-on-one in their rooms. There is never a set of circumstances where they should be left to eat alone.
Like with nursing home falls, the occurrence of a nursing home choking accident tends to forecast the occurrence of additional ones unless proper precautions are taken. Sadly, that it is exactly what occurred in this instance.
On February 1, 2019, a CNA responded to the resident’s call light. When she entered the room, she saw that the resident was choking and that there was a dinner plate on the bedside table. The CNA called for help. The staff was unable to access the resident’s airway because the resident;s jaw was so tightly clenched. 911 was called and the paramedics retrieved a large amount of food from the resident’s airway. The paramedics took the resident to the hospital where he was died shortly after arrival.
If I were investigating this incident as a nursing home wrongful death lawsuit, there are a number of issues that would be a source of concern to me:
- This resident was admitted to the nursing home with an order for a puree deit which was upgraded to a mechanical soft diet. It is possible to choke on a mechanical soft diet, so the issue of whether the resident was appropriate for an upgrade to mechanical soft diet is one worth examining. Doctors customarily rely on the judgment of the speech therapist in upgrading a resdient’s diet from puree to mechanical soft, so the role of the speech therapist in this choking incident is worth close examination.
- How did the resident get this tray and how did he come to be unattended at meal time? This was a resident who required assistance with eating and was not supposed to be left unattended at meal time, yet this is exactly what happened. The kind of risks that this resident faced of choking is not the most common safety hazard for nursing home residents, but is far from rare. Well-run businesses (and nursing homes are a business) run on systems which make ensure that the services promised get delivered every time – as long as the system is followed. Did this nursing home really have a system for making sure that aspiration precautions were followed or was there a simple breakdown in the system and this resident paid the price? These are the questions that I would try to see answered in a nursing home abuse and neglect lawsuit.
- The director of nursing admitted that the facility had no policies and procedures regarding aspiration precautions, just practices that were followed. Were the aspiration precautions that this resident needed actually incorporated into a care plan addressing the risk of aspiration or choking or was the delivery of this crucial care item left to random chance?
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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