IDPH has cited and fined Riverview Rehab nursing home in Elgin after a resident there choked to death while being fed by an aide.
One of the functions that a speech therapist plays in the care of nursing home residents is assessing the resident’s ability to eat safely. This is done by assessing the resident’s swallow function. If there are issues with the resident’s swallow function, then the speech therapist will make recommendations for a modified diet and other safety precautions. Left unaddressed, difficulties with swallowing can lead to a nursing home choking accident or aspiration pneumonia.
The recommendations made by the speech therapist are usually incorporated into the resident’s care plan or physician orders. Either way, these precautions are critical to safety and well-being of the resident and must be carried out on a day-to-day, shift-to-shift basis. Failing to do so can lead to disastrous outcomes.
The resident at issue was assessed by the speech therapist who determined that the resident was at risk for aspiration because of dysphagia (difficulty swallowing), brain injury, and communication deficits. The resident was placed on a modified diet with mechanical soft foods and thickened liquids. The resident had a history of eating very quickly, but was allowed to feed herself with supervision. The staff was specifically instructed to make sure that the resident finished each bite and swallowed before taking the next one.
On the morning of the accident, the resident was being fed by an aide who was aware that she was at risk for aspiration. The resident started feeding herself but was eating too quickly so the aide took the meal away and began to feed her. However, the resident did not want to be fed, so the aide returned the tray to her and continued to watch her eat. Gradually, the aide came to realize that the resident was “not looking good,” so she she went and got another aide who told her to get a nurse. When the nurse arrived, the resident almost immediately lost consciousness, so the nurse cleared food from her mouth and began to do CPR.
911 was called, but when they arrived the resident had no pulse. They were able to regain a pulse and brought the resident to the emergency room. The resident was admitted to the intensive care unit, but the extent of the brain damage was so significant that the family placed her on hospice. She died six days after the choking incident. Cause of death per the death certificate was “Complication from aspiration of food bolus.”
There were many things that the nursing home did right here, but a couple of breakdowns in the care led to the death of this resident. On the plus side, they got a proper assessment done of the swallow function and came up with a modified diet and steps to address her risk of choking. The fact that the she was at risk for choking and what should be done was also properly communicated to the staff on the floor.
Where the care that this resident received failed was in two respects. First, the tray was returned to the resident after she demonstrated impulsive eating behaviors and would not be fed by the staff. The speech therapist and the Director of Nursing both agreed that the proper course of action here would have been to take the tray away, check the resident for pocketing of food, and alert the nurse. Second, the aide failed to recognize that the resident was choking, failed to alert the nurse immediately (rather than another aide), and failed to take steps to clear the resident’s airway. The minutes of delay when the resident’s airway was compromised was critical time lost to indecision.
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