Woodhaven Nursing Home, located in Suffolk County, was fined $21,937.50 by the Department of Health after an unsupervised resident choked on a sandwich in December, 2013. The resident was allowed to eat unsupervised despite being a known choking risk due to underlying conditions including dysphagia and impaired cognition. The nursing home had also implemented an aspiration precaution careplan for the resident. He died as a result of the choking incident.
Because Woodhaven had placed aspiration precautions in the resident’s careplan, staff was not supposed to give him any food that could lead to choking. Rather, his diet was to consist of pureed solids and/or honey thickened liquids. Additionally, staff was to assist the resident while eating until each meal was finished. Numerous notes in the resident’s chart throughout and leading up to the incident document his dietary restrictions. On December 11, 2013, the 24-hour note states that he had expired during the night shift. This particular note contains no other information on the resident.
Details of the patient’s death are not recorded until a Nursing Note dated the following day. According to the note, the patient choked while eating a sandwich. Despite resuscitation efforts (Heimlich and suctioning), the staff was unable to revive the man. A separate Nursing Note suggests that although staff were present at the time of the incident, they were not assisting the resident with eating. Staff did advise the resident to eat more slowly, however he did eventually choke on the sandwich and subsequently passed away.
As it often does in cases such as this, the DOH conducted numerous interviews with staff at Woodhaven. One such interview of particular interest was conducted with the Medical Director of the nursing home. He told the Department of Health that he was not aware of a system in place for aspiration precautions. He also told the DOH that he could not recall ever reviewing a policy on aspiration precautions. The Director of Nursing, in her interview with DOH investigators, stated that she did not believe that neglect had occurred “because staff did not intentionally force food down his mouth.”
As has been documented many times before on this blog, it is the duty of a nursing home to ensure that the resident environment remains as free of accident hazards as possible. The nursing home must provide adequate supervision to residents to ensure that accidents do not occur. “Accidents” can include choking incidents, such as the one described above, falls, fractures, and any number of other incidents that may occur at a nursing home. Unfortunately for the man and his family who put their trust in Woodhaven to care for him, this incident ended in tragedy.
The entire Department of Health survey can be accessed here.