IDPH cited and fined Glenwood Healthcare & Rehabilitation Center after a resident choked to death.
The resident was 59 years old and had a diagnosed swallowing disorder and suffered from severe mental impairments. There was a physician order in place for a mechanical soft diet. A mechanical soft diet is provided to nursing home residents who have chewing or swallowing disorders to help prevent nursing home choking accidents.
On the day in question, the resident was provided with a fried chicken sandwich. This was what was being provided that day to residents on a general diet, not the mechanical soft diet, and in any event is something that is completely inconsistent with the mechanical soft diet. An aide saw that there was no one there to supervise the resident and he was stuffing food into his mouth – a behavior that the aide told the surveyor that “all the staff knew about.” The aide went over to tell him not to do that and he accidentally spit some of the food out onto her face. She left to go wash off her face without taking the tray away from him and without telling another staff member to watch him.
When she returned from the bathroom, she recognized that he was choking. She alerted a nurse and they attempted the Heimlich, getting some food out of his mouth and then started CPR. Paramedics came to the nursing home and he was taken to the hospital where he was declared deceased in the emergency room.
There are several levels of failures which led to the wrongful death of this nursing home resident:
- The resident was obviously at risk for choking based on his well-known behavior of stuffing food in his mouth. He suffered severe mental impairments which made relying on him to act in a manner which assured his own safety was folly. He was not able to control his own behavior. This risk required a specific care plan to address a known safety risk. This is the kind of resident for whom the kind of supervision that is provided at a feeder table was intended. Yet, that was either not a part of his care plan or the care plan was not being followed.
- He was provided with food that was not consistent with his physician-ordered diet. Each resident has a diet card which specifies what they are supposed to be getting. This resident was provided with the wrong meal.
- Once the aide saw that he was eating food which was not mechanical soft diet foods and that he was eating unsupervised, the right move at that point was to take the tray away, make sure that the resident’s mouth was clear, and make sure that he was being supervised. From a human behavior standpoint, wanting to get food that was spit on you cleaned up is understandable, but at that moment, the aide was the only thing standing between the resident and a potentially fatal hazard. She needed to make sure that he did not have food that he could choke on and that he was being supervised before getting cleaned up.
One thing that we see often in nursing home abuse and neglect lawsuits, especially accidents like nursing home falls, is that the injury producing event has roots that were planted weeks, if not months earlier. Had this resident been care planned for an obvious choking risk and assigned to a feeder table, he would never have been allowed to start eating that fried chicken sandwich and there would have been supervision on hand. Even with that failure of care planning early on, the staff knew about behaviors which showed a choking risk. Nonetheless there was apparently no care plan in place to address that choking risk. The aide who left to clean up played an immediate, obvious role in producing this man’s wrongful death, but there were many contributors to this over the days, weeks, and months leading up to this incident.
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 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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