The New York State Department of Health (DOH) fined the Loretto Health & Rehabilitation Center, a 585-bed facility located in Syracuse, New York, $5,000 after an unsupervised Alzheimer’s patient choked to death. According to the DOH report about the incident, the resident was admitted into the facility on July 16, 2012 after she underwent hip-repair surgery. The hospital’s discharge notes, which need to be reviewed by the nursing home’s admissions department, indicated that the resident should be restricted to a diet of “nectar thick liquids.” In addition, the hospital’s instructions stated that the patient was at risk of choking and needed “total assistance with oral intake.”
On the evening of July 17, 2012, the patient was served kielbasa for dinner and was sitting unattended at a dining table. A licensed practical nurse (LPN) told investigators that she and a family member observed the elderly patient eating her dinner by herself. The LPN stated that the family member was “pleased” that the resident was eating independently. About a half hour later, the LPN saw that the resident was “slumped over in the chair” and told investigators that “she looked like she was already gone.” The LPN stated that she didn’t think that the patient had choked because the resident didn’t have any eating utensils in her hands. After finding the resident unresponsive, the LPN informed her on-duty supervisor. The two nurses then wheeled the woman back to her room and laid her on the bed. The supervisor stated that the resident’s airway was clear of any food. In addition, because the resident had a DNR, the nurses did not attempt to perform any life-saving measures. The supervisor pronounced the woman dead at 6:05 p.m.
A forensic autopsy performed on the same day indicated that the patient had choked to death on a piece of kielbasa. The DOH report concluded, “The facility did not have a plan in place to monitor the resident related to aspiration precautions, and did not provide emergency treatment when found unresponsive in the dining room at meal time.”
In another deficiency citation, the DOH observed that the facility failed to follow the feeding and diet restrictions of a dementia patient. According to the resident’s care plan, the patient had a history of “pocketing” food in the corner of her mouth. The plan stated that the resident was at risk for choking and should be monitored while eating. Moreover, the plan indicated that the resident should eat while sitting at a 90 degree angle. However, a DOH investigator observed that the patient was slouched over while eating alone without the assistance of any staff member. As a result, the facility was cited for failing to follow “the plan of care for aspiration precautions, as identified in the comprehensive care plan.”