The Hartford Courant reported that another choking death of a nursing home resident. One of the most unnecessary and preventable dangers in nursing homes are food related injuries and deaths as a result of neglect.  Patients who are cognitively impaired and require special diets have become victims of neglect. These patients, in their impaired state, are given food they cannot consume.

An incident at Paradigm Health Care Center in Norwalk, represents at least the fifth choking related death in Connecticut nursing homes in the past ten months.  Researching developmentally disabled deaths in group homes and nursing homes, The Courant, a Hartford newspaper, found 76 cases of deaths from 2004-2010.  In all of these cases, abuse, neglect, or healthcare error was a contributing factor.  Of these deaths, 14 were on special diets and choked to death after eating food they should never have ingested.

Incidents like these, where patients die as a result of choking from food they should never have eaten are too common within nursing homes. Upon further investigation, there were a number of instances of improper food consumption within Paradigm. The facility was fined just over $1000 and had to submit a plan of correction to the Connecticut Department of Public Health.

How much do you believe a life is worth? Because the Connecticut Department of Public Health has consistently said that a life is only worth a thousand dollars.

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The Hartford Courant reported that in a mere three months, four residents in Connecticut nursing homes have choked to death. That is outrageous neglect.  The most recent death occurred at the Lutheran Home in Southbury when a nursing aide failed to read a resident’s feeding instructions and served the resident, who was on strictly soft-food only diet, a large chunk of ham and a hard cookie. The dietary aide who prepared the resident’s food knew the resident was on a soft-food diet and had ground meat prepared and available.  However, he elected to serve him whole piece of ham instead because he “though it was soft enough to eat.”  The resident required extensive assistance with eating yet the CNA in charge of helping him eat admitted that she “thought the resident was on a regular diet” so did not bother to read his diet slip.

Incredibly, when the resident began to choke and cough, nurses attempted to cover up the negligence by moving the wheelchair-bound resident to a utility room before administering aide.   By the time the resident was moved and Heimlich Maneuver was attempted it was too late. The resident died before medics could reach the nursing home.  I wonder how long they waited to call 911? What kind of training did the nurses have that they could not provide emergency care?

The Lutheran Home administrator defended the facility saying that they do not “specifically instruct nurses’ aides to check the special dietary orders before meals because that is supposed to be part of the aides’ certification training.”

What the heck does that mean?  Clearly the training and policy and procedures at this nursing home needs improvement.  Sadly, the state health department only fined the Lutheran Home a mere $615 out of a maximum $3,000 and allowed the facility to keep their license.  I hope additional training will be part of the solution.   It is tragic that such carelessness can occur with so little consequence.

The Hartford Courant reported on the tragic and preventable death of a nursing home resident. The death occurred at the Aurora Senior Living Center in Cromwell, Connecticut. The incident happened when a nurse improperly authorized a visitor to give the resident a marshmallow and she choked to death. The nurse failed to failed to check the resident’s diet restrictions and was not aware that the resident was on a ground-food only diet by doctors orders. The resident had dysphagia, or difficulty swallowing, and required intensive assistance while eating, including reminders to swallow. During the incident the resident became unresponsive and went into cardia arrest. She died two days later at a nearby hospital.

 

The Hartford Courant had an article on the tragic death of a nursing home resident who choked on a peanut butter and jelly sandwich.  It was well known that the patient needed assistance while eating.  Because of short staffing, the resident was left unattended with the fatal sandwich. 

State inspectors said staff members at Torrington Health and Rehabilitation Center, whose parent company is Spectrum Healthcare Torrington, were required to carefully monitor the elderly patient, who suffered from mental illness and pulmonary disease. The staff was instructed by doctors to encourage the resident to eat slowly and take small bites, and to cue the resident to chew and swallow. Food had to be cut up in small pieces.  Despite this treatment plan, inspectors reported, "staff failed to supervise the resident when the resident was left unattended with a peanut butter and jelly sandwich.”

The patient was found unconscious. Medics performed CPR and the ambulance report indicated the resident’s airway was completely blocked with peanut butter. The patient died at a hospital of cardiac and respiratory arrest, and choking, according to the state Department of Public Health inspection reports.

 

The Austin Daily Herald reported the tragic and preventable death of Wayne Bye from choking.  The resident who had swallowing problems was left unattended and unsupervised while eating.  Adams Health Care Center is accused of neglect when Bye choked to death in his room on March 18, 2011. According to a Minnesota Department of Health report, Bye was not adequately supervised while eating, and he was found choking in his room with no staff present. Bye went into respiratory arrest, according to the report, and passed away during the incident.

An employee was in the room when Bye started choking. Then, two nurses entered the room and confirmed he had stopped breathing and had no heart rate. A nurse said a couple of bites of fruit were eaten, and Bye’s lips were blue, according to the report. The nurse said no emergency interventions were performed.

Bye’s medical record stated that he was at risk for aspiration pneumonia and had difficulty swallowing. Staff was supposed to make sure Bye swallowed each bite twice, ate slowly and elevated his head 90 degrees while eating and 45 degrees for 30 minutes after eating.

He was to be returned home the day he died.  See article from the Star-Tribune.

NBC’s TMJ4 reported the jury verdict for a woman who choked to death at a nursing home.  This preventable neglect occurs more often than it should because of understaffing, poor supervision and poor training.  The jury compensated the family $1.5 million for the 56 year old’s death.  The verdict included compensation for medical bills and funeral expenses, pain and suffering, loss of society and companionship and $775,000 in punitive damages, totaling $1.5 million.

She had a history of difficulty in swallowing.  Evidence showed that bad weather in February of 2009 had prevented all but one caregiver from arriving at work. The caregiver on that day did not puree Vicky’s food and she choked, suffering brain damage and passed away a week later.

 

 

The Detroit Free Press ran a series of articles on the atrocious care at Michigan nursing homes.  The series was called aptly "Trust and Neglect".   One article discussed several preventable deaths at facilities, many of which were not investigated or reported.  Below is a summary.

Walter Polomski choked to death on a golf-sized meatball (he was supposed to be on a pureed diet) on Easter Sunday 2008 because understaffing led to a lack of dining room staff to help him.   Last month, a Macomb County jury awarded Polomski’s family $2.35 million for its pain and suffering from his death.  It was a SAVA facility.

Emeline Falls died in November 2010 after being given her roommate’s diabetes medication.  The facility’s surveillance tape showed a nurse taking a single dose of the medicine into the women’s room, returning to her cart, studying the photos of the roommates, and bringing in a second dose of the same drug.

Helen Hoover died last year after a new and poorly trained aide dropped her from a mechanical swing used to move patients needing extra support.  The lift should only be used with two assistants.  Hoover fell to the floor, her ankles caught in a lift sling, blood pooling under her head.  The state cited the home for failing to prevent an accident and ineffective administration.

Grace Reid fell from her wheelchair in 2008, breaking her neck in the dining hall of Heartland Health Care Center-Georgian Bloomfield in Bloomfield Hills.  The state cited the facility for failing to prevent accidents and failing to adequately investigate the accident or report it.

Verdun Newkirk breathing had changed and he began staring off into a corner of the room. By the time an aide alerted a nurse, and staff confirmed that Newkirk wanted to be resuscitated, Newkirk had been dead for seven minutes. CPR was never performed. The facility was cited for failing to provide "quality of care."

Harry Taylor died a bloody death. Blood soaked into bed linens, his clothes and into the carpet. Yet his death certificate recorded his last moments as the inevitable end to heart disease.  His death was never investigated or reported to the State.  According to police, an employee at Heartland Health Care Center-Canton found Taylor on the floor of his bedroom in July 2008 — blood surrounding his head and chest. The worker screamed, and someone called 911.  But the examiner, Dr. Leigh Hlavaty, only saw the cleaned body of an 82-year-old man with a history of heart disease. She ruled it a natural death. Only later after medical documents and photos of the bloody scene were provided was it changed from a natural to an accidental death.

These are just a handful of examples of the neglect and preventable deaths that occur in nursing homes every day.  When will it get better?  

The NY Times had an informative article on the state of care in New York’s adult homes.  The Times undertook its own analysis of death records and found disturbing patterns: some residents who were not supposed to be left alone with food choked in bathrooms and kitchens. Others who needed help on stairs tumbled alone to their deaths. Still others ran away again and again until they were found dead.

In New York, it is unusually common for developmentally disabled people in state care to die for reasons other than natural causes.  "One in six of all deaths in state and privately run homes, or more than 1,200 in the past decade, have been attributed to either unnatural or unknown causes, according to data obtained by The New York Times."   State officials in New York cannot even agree on how many people are dying. The Office for People With Developmental Disabilities says 933 people in state care died in 2009. The Commission on Quality of Care says 757 did. Neither agency could explain the discrepancy.

New York has made no effort to track or investigate the deaths to look for patterns or trends, resulting in the same kinds of errors and preventable deaths, over and over.  The state does not even collect statistics on causes of death, leaving many designated as “unknown,” even after a medical examiner has made a ruling.

The records shows neglect may be contributing to those unexplained deaths. The average age of those who died of unknown causes was 40, while the average age of residents dying of natural causes was 54.

New York, like most states, relies heavily on the operators of the homes to investigate and determine how a person in their care died and, in a vast majority of cases, accepts that determination without investigation or corroboration.  Courtney Burke, the commissioner of the Office for People With Developmental Disabilities, which operates and oversees thousands of group homes, acknowledged that her agency suffered from a lack of transparency and what she called “a culture of nonreporting.”

The problems in the New York system appear especially troubling given that the state spends $10 billion a year caring for the developmentally disabled — more than California, Texas, Florida and Illinois combined — while providing services to fewer than half as many people as those states do.

 

Illinois’ The State Journal Register reported the $2,200 fine issued to North Church Nursing & Rehab for failing to supervise a patient who died from choking on food.  State officials recommended that federal officials level a separate, $7,600 fine against North Church, a 113-bed for-profit facility that previously was known as Golden Moments Senior Care Center.

According to the investigation report, the resident was eating a sandwich unsupervised when she began to choke and passed out.  She was pronounced dead in the Passavant Area Hospital emergency department about 6:45 p.m. Sept. 23.

In a similar incident, the state issued a $50,000 fine against the facility, then known as Golden Moments, for poor care connected with the Oct. 3, 2009, death of Adam Waeltz, a 74-year-old patient who choked on food.

A Michigan jury in Macomb County compensated the family of a resident $2.35 million after he
died from choking on a meatball in a Sava nursing home. After an eight day trial and careful
deliberations, the jury concluded that Sava Senior Care Inc., which owned and operated Nightingale Nursing Center, was negligent and caused the death of Walter Polomski, 56, who choked on a golf ball-sized meatball and died after going 15 to 30 minutes gasping for oxygen.  Sava is owned by Murray Forman who also owns and operates the Fundamental Long Term Care Holdings chain of nursing homes.

Sava claimed their subsidiary, SSC Warren Woods Operating, the name on the license, should be
the only Sava entity responsible.  The family’s attorney, John Perrin, said “People need to know that the name on the building isn’t always the company that’s operating the facility,” Perrin said. “There are a lot of shell companies.  Because the real owners don’t put their name on the building, they don’t provide good care.”

Walter Polomski died March 23, 2008, four hours after a meatball got stuck in his trachea
instead of going down his esophagus about 11:35 a.m. at lunch. Polomski never should have had
been given the meatball because he had swallowing problems with doctor’s order for altered
foods. The sole nursing home staffer in the dining room didn’t know the Heimlich maneuver and
instead wheeled him 40 feet or more to a nurse’s station. Another nurse unsuccessfully
performed the Heimlich maneuver on Polomski in the wheelchair then placed him on the ground.
Then another poorly trained nurse tried to force air into his lungs with an “ambu bag,” which
exacerbated the problem. The nursing home failed to call 911 for at least 12 minutes, or properly
staff the dining room, where there should have been at least five staffers. EMS arrived quickly,
and a paramedic removed the meatball with forceps. Polomski died at the hospital on Easter Sunday.

The jury awarded $1.5 million for Polomski’s pain and suffering, $750,000 for the family’s past
“loss of society and companionship” and $100,000 for future loss of companionship. Two jurors
said they agreed Sava was negligent but disagreed with the amount awarded.

The victim’s brother, Richard Polomski was emotional following the verdict.  “I’m ecstatic because my brother’s story was told and I got to find out what exactly happened to him,” Polomski said. “The nursing home was not telling me what EMS was telling me. That’s what prompted me to file a lawsuit.”

Defendants tried to ignore their responsibility by claiming that Polomski’s life expectancy was
only about four to 10 years.