A nursing home in Danbury, Conn. was fined only $1,040 by the state’s Department of Public Health after one of its residents died from choking on a meatball. The incident occurred when a licensed practical nurse left the resident’s evening meal tray at the individual’s bedside and left the room for the medication cart.  The resident was known to have swallowing problems and at risk for choking.  When the nurse returned, the resident was unresponsive. Records show that the tray was covered and that there was no visible food in the resident’s mouth, however.  The staff did not properly assess or care plan for the issue as the vulnerable resident was on a regular diet with cut up meat and thin liquids with no supervision.

The resident was taken to a hospital where the meatball was removed. The individual later died as a result of aspiration leading to hypoxic encephalopathy, which is a lack of oxygen to the brain.

The nursing home’s dietary director told state investigators that the kitchen staff was not responsible for ensuring that food was cut up for residents who have difficulty swallowing. Records show, however, that the meatballs served with the spaghetti that night were three-quarters to 1 inch in size and were considered appropriate for a soft diet.

This incident is not the only one to involve a resident choking on food, as state officials in Connecticut fined at least five nursing homes when their residents experienced similar cases. In some cases, the Department of Public Health found that negligence was to blame.  See article.

 

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