IDPH has cited and fined Rosewood of St. Charles nursing home after a resident there choked to death during dinner.
One of the fundamenentals of delivering care in a nursing home is that when there are steps identified in the resident care plan that have to be taken to assure the safety and well-being of the resident, these need to be carried out on a day-to-day, shift-to-shift basis. When nursing home staff fails to carry out a resident care plan, disaster can result – and that is what happened here.
The nursing home here actually did many things right in carting for this resident. The resident was suffering from Alzheimer’s and was known to the staff to be someone who ate very fast. The staff in various parts of the citation described her as “gobbling” or “scarfing” her food down while she ate, noting that sometimes she chewed her food and sometimes she didn’t. The aides and other staff described frequently needing to remind her to slow down while she was eating. They referred her to a speech therapist who noted issues with chewing, swallowing, and pocketing of food while she ate. She was downgraded to a mechanical soft diet with thin liquids and an order was obtained for four weeks of speech therapy to work on swallowing. Her care plan called for her to to eat in an assisted dining room at a feeder table and to be monitored during meals.
These are all reasonable steps to take – as long as they are taken. And that was where the problem here arose.
In the assisted dining room, there were usually at least three aides in the dining room during meals. One of them would be seated at the feeder table to provide direct supervision and assistance to the residents who were seated there. The speech therapist told the state surveyor that the resident at issue needed to be under direct eye contact supervision while she ate because of her chewing and swallowing issues.
On the night of the incident, there were were only two aides in the assisted dining room because the others were running late. The aides instructed the dietary aide to start passing the trays eve though no one was seated at the feeder table. While the aides were pouring drinks to the other residents, the resident began to eat and started to choke. The staff attempted the Heimlich and was able to get a small piece of meat out, but the resident was stil not breathing and began to turn blue.
Paramedics happened to be in the building because they were returning another resident from a doctor appointment. The offered to help and were able to clear more food from the aiway doing the Heimlich. They began to try to resuscitate the resident and brought her to the emergency room. However, her heart stopped while she in transit to the emergency room. There was already a DNR in place, so further efforts at resuscitation were stopped, and the resident was declared deceased.
This resident’s death was a direct result of failing to carry out a reasonable care plan. This resident required direct, eyes-on supervision while she was eating because of her habit of eating very quickly when she had known swallowing and chewing problems. The combination of the two are a formula for a nursing home choking accident which is why that level of supervision was needed. However, the assisted dining room was not fully staffed when the instruction was given to start passing the trays, and as a result, the resident did not get the level of supervision she needed, with disastrous results.
The deeper question of course is why the aides who were supposed to be in the assisted dining room that evening were running late. A possible answer to that would be that they had to much other work to get done for them to make it into the assisted dining room in time. That in turn raises questions about understaffing of the nursing home which is a feature of the nursing home business model. 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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