A Bronx long-term-care facility, Morris Park Nursing Home, was recently cited and fined $10,000.00 by the New York State Department of Health. The citation and fine are the result of an incident where a 68 year-old resident choked to death during dinner.
Under state and federal law, nursing homes must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Based on staff interviews and record review during a complaint survey, the surveyors concluded that Morris Park failed to ensure that the resident received adequate supervision to prevent accidents.
The resident, a 68 year-old male, had a history of wandering, stealing food, as well as a host of medical conditions that made aspiration and/or choking a risk. According to the various nursing home records, the resident had chewing and swallowing problems and requires limited assistance of one person during eating.
The nursing home’s Eating/Feeding Comprehensive Care Plan (CCP) initiated on 2/26/10 documented that the resident required intermittent supervision with set up related to impaired cognition, vascular Dementia, CVA, Dysphagia and high risk for aspiration. On 8/13/10 after readmission to the facility the feeding requirement changed to limited assistance during eating. Interventions included verbal cues, providing limited assistance in feeding, assessing feeding status quarterly or as needed, referring to speech therapist for swallowing evaluation, providing with ordered diet and liquids, and observing for aspiration precautions.
On 8/15/10, between 5:15 PM and 5:20 PM, the CNA assigned to the resident served him his dinner in his room. He had a pureed meal with thickened liquid and soft fruit juice. The CNA stated that the resident’s roommate, who is on a chopped consistency diet, was also eating in the room. The CNA set-up the food and then left the room to watch other residents in the dining room.
At approximately 5:25 PM the CNA saw the resident walking from his room towards the nurse’s station. The resident’s face looked dark red and he had slurred speech. The CNA walked down the hall with the resident towards the nurse’s station and then he collapsed. The CNA called the nurses for help and they sat the resident on a chair. The RN checked the resident’s vitals and then called a code. The resident was then put to bed and CPR was started. The CNA stated that the resident’s “color was changing so fast as soon as we put him to bed and his eyes were closed”.
The EMS personnel arrived and continued with CPR. The resident was suctioned and intubated. EMS personnel reportedly pulled a processed peach measuring 3 cm (centimeter) by 1 cm out of the resident’s mouth. The resident expired at 6:15 PM. The EMS personnel then told the RNS that they found a peach in his throat during intubation.
The surveyors cited the facility for not providing the adequate amount of supervision during his dinner. The DOH report did not indicate where the resident found the peach.
Morris Park Nursing Home NYS DOH Complaint Survey, March 18, 2011.
If a loved one has suffered due to a choking incident at a nursing home, please contact the Nursing Home Attorneys at the Law Offices of Thomas L. Gallivan, PLLC for a free consultation.
