Jonathan Rosenfeld's Nursing Homes Abuse Blog : Jonathan Rosenfeld's Nursing Homes Abuse Blog | Lawyer & Attorney : Strellis & Field Law Firm | Bed Sores, Senior Neglect, Elder Abuse, Sexual Abuse: Chicago, Illinois

I think most people would be amazed if they became aware of how many injuries and deaths were cased by an employee's failure to follow basic orders.  This time, a hospital employee's failure to follow basic instructions related to a patient's dietary needs has cost another patient their life.

Ignoring doctors orders, an employee at Mayers Memorial Hospital gave a meat and cheese sandwhich to an Alzheimer's patient who was unable to eat solid food.  Left unattended with the sandwhich, the patient literally 'inhaled' the sandwhich.  Five days later, the patient died from pneumonia caused by inhaling food.

According to California Department of Public Health Director, Dr. Mark Horton, "The facility failed to protect the heath of a patient when the prescribed diet ordered by the phyisician and in the patient's care plan was not followed.  As a result, the patient died."

The California Department of Public Health issued a AA citation and a $50,000 fine to the hospital following its investigation.

Read more about this choking incident here.

Pneumonia from inhaling food?

Yes.  Many nursing home and hospital patients develop 'aspiration pneumonia' when food or foreign materials enter the bronchial tree (lungs). Aspiration pneumonia may result after oral or gastric contents (including food, saliva, or nasal secretions) are inhaled. Depending on the acidity of the materials inhaled, a chemical pneumonitis can develop, and bacteria may add to the inflammation.

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The effectiveness of feeding tubes in dementia patients is questionable-- according to a study to be published in the Journal of the American Medical Association.  The study carried out by Dr. Joan Teno evaluated a sampling of nursing home patients who had been admitted to acute-care hospitals between 2000 and 2007.  In addition to a questionable improvement in the quality of life of dementia patients, the study determined that this group was more likely to receive a feeding tube if they received medical treatment at large, for-profit hospitals.

Feeding tube use amongst dementia patients is extremely common.  According to a Business Week article, more than one-third of dementia patients in nursing homes currently have feeding tubes, with the majority of those being inserted during an acute care-hospitalization.

One reason possible reason for the frequency in the insertion of feeding tubes during acute hospitalizations may be due to the fact that when dementia patients enter a new environment-- such as an acute-care hospital, they have a difficult time adjusting to the new environment and may not immediately eat.

"They often get very stressed out, have disruptive behavior, get medications to treat that behavior, which leads them to developing bed sores and problems with eating, which leads to having a feeding tube inserted," according to Teno. "Part of what we need to do is align the incentives to keep frail older dementia patients in the least restrictive setting that will provide the best medical care."

As an alternative to feeding tubes, some experts suggest 'spoon feeding' patients.  Using a spoon feeding method, a person literally feeds the person with a spoon at his or her own pace.  Some experts suggest that spoon feeding may not necessarily prolong the life of the individual, but it can improve the quality of it. 

Patients who have feeding tubes in a nursing home or hospital setting are at risk for a variety of medical complications including:

Gastroesophageal reflux caused from gastric juices being forced back into the esophagus can occur with feeding tubes because the tubes sometimes cause a delay in the emptying of the stomach. This means that a person has to have more frequent, smaller feedings.

Clogging: Most feeding tubes are very narrow, and commercial tube feeding formulas such as Ensure, are designed so that they will not clog the tube; they are not too thick and do not leave a residue. Most formulas are designed to have water added to them to ensure that the patient is receiving enough dietary water, and to further thin the formula for ease of use. Staff should flush the tube with water before and after feedings, or after medications have been administered through the tube.  The use of noncommercial formulas is discouraged, because there is a greater likelihood that they will contribute to clogging. After the tube is placed, a registered dietitian or a nurse who specializes in nutrition should assess the patient to determine their nutritional needs, the amount of calories, protein, and fluids that will be necessary, as well as the most appropriate nutritional formula and how much of that formula will be needed each day. 

Nausea and vomiting is a common problem with feeding tubes. It occurs when liquid food is administered to an individual through a tube too quickly, or when the formula provided through the tube is too high in protein and/or calories. Migration (shifting) of the tube, bacterial infections and air in the stomach can cause nausea and vomiting as well.

Leakage is a complication of feeding tubes that occurs typically because the size of the stoma around the tube has increased, or because the position of the tube is improper due to bad placement or general shifting. This problem sometimes requires replacement of the tube, and it forces an individual or attending physician to keep the stoma clean with protective gauze and ointment.

Constipation occurs frequently with feeding tubes because the liquids that are administered through the tubes don't always have as much bulk or fiber as normal foods. Without fiber, an individual's digestive system has trouble retaining enough fluid and staying regular enough to produce frequent bowel movements. This problem means that the individual either has to find a way to introduce liquids that are higher in fiber through the tube (which can increase the risk of the tube clogging), or she has to take medications to relieve constipation.

Choking / Aspiration can occur if an individual is administered food through a feeding tube while in an improper position. This can result in choking, coughing and pneumonia. These, in turn, can aggravate the stoma, because the abdominal wall is forced to engage forcefully during a cough or sneeze. The aggravation of the stoma can lead to further infection. Most medical professionals suggest feeding patients when they are as up-right as possible to avoid aspiration on the food.

Many of these problems can be avoided when facilities employ adequate numbers of properly trained staff.  Consequently, if you have a loved one who require tube feeding, it is important to check with the facility to make sure they are accustomed to handling patients with these medical needs.

Resources:

Too Many With End-Stage Dementia Get Feeding Tubes, BusinessWeek, February 9, 2010

Common Complications of Tube Feeding

Nursing Home Staff Must Pay Special Attention To Avoid Complications When Caring For Patients Dependent On Feeding Tubes

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The Exceptional Care nursing home is a small 55 bed nursing home located in Burbank, IL. According to the government’s Medicare website, the facility received only one out of five stars, which is a much below average rating. The facility received only two out of five stars for health inspections, which is a below average rating.

Exceptional Care is not living up to its name.  In the past year, the nursing home had five health deficiencies, which is three less than the average number of health deficiencies in Illinois and in the United States. This is down from the twelve health deficiencies in the previous year.

Every nursing home has an obligation to provide a safe and secure facility for its residents and to provide proper care and supervision to achieve and maintain the highest level of well-being for its residents. Nursing homes must meet the Requirements for States and Long Term Care Facilities outlined in 42 CFR Part 483.

According to survey reports, Exceptional Care received violations for failing to:

• Provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident
• Provide or arrange services that meet professional standards of quality

According to survey reports, the facility failed to provide an ongoing program of activities as required under federal law. Many nursing home residents have activity care plans to help treat conditions, especially depression.

Several residents with activity care plans calling for one-on-one programs or group activity were never taken out of their rooms to attend group activity. In addition, the facility did not have adequate activities scheduled on several afternoons. Furthermore, several planned activities never occurred, had very low attendance, or had no staff to resident interaction.

The survey also revealed that the services provided or arranged by the facility did not meet professional standards of quality. Nursing home staff failed to properly administer medications as ordered for several residents and failed to clarify orders to provide proper treatment for residents.

The facility also failed to ensure a medication error rate of less than 5%. During the survey, 45 medication opportunities were observed, with four medication errors, resulting in a medication error rate of 8.88% for four of fourteen residents observed. The facility also failed to ensure that residents are free of any significant medication errors when staff failed to administer an ordered anti-psychotic medication for two weeks to a resident suffering from Bipolar disorder resulting in disruptive behavior.

The facility also failed to thoroughly investigate unwitnessed and unknown injuries for a resident who was found with bruises on multiple areas of the body. Nursing home staff failed to conduct an investigation into the cause of the bruises.

Nursing homes are charged with providing the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of its residents. The facility failed to meet this requirement by failing to follow swallow precautions for a resident who was identified with a high risk of choking.

Exceptional Care received only one out of five stars for nursing home staffing. The facility has 37 total residents, compared to the national average of 94.7 and the Illinois average of 103.9. Each resident received 59 minutes of nursing home staff time per day, which is less than the Illinois average (1 hour 12 minutes) and less than the national average (1 hour 24 minutes).

This two-star rated facility has many deficiencies, which might be a troubling sign that nursing home residents might not be receiving the proper care and attention they need and deserve.

Sources:
Medicare website
IDPH website

Related:

When Bruises Can't Speak For Themselves: The Difficulty Proving Abuse Of Disabled Nursing Home Residents 

Who Should Manage Administration Of Medication?

Welcome To The Nursing Home. Let's Begin Our Assessment and Care Planning

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Tustin Care Center, located in Orange County, California, was fined $50,000 by the California Department of Public Health for the choking death of one resident in March 2009.  The California Department of Public Health concluded that the facility’s failure to assess the resident’s ability to eat was a direct cause of his death. 

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A nursing home cook and nursing assistant have been fired following the death of a 54-year-old schizophrenic patient at a California nursing home.  The incident took place at the Raintree Convalescent Hospital.  Despite the fact that Raintree documented the patient's swallowing problems and ordered all food to be sliced or pureed to accommodate his swallowing problems, the man was served whole meatballs.

According to a an investigation by the California Department of Public Health, the man stumbled out of his room, pale and unable to speak after he was served whole meatballs.  A nurses attempt to do the Heimlich maneuver on the man was unsuccessful and he was pronounced dead a short time later at an area hospital.

This is a case where the facility admits that its staff failed to follow standing orders with this patient.  According to Antonio Sandoval, assistant administrator at Raintree Convalescent Center, the cook and the nursing assistant ignored the residents care plan when they served whole meatballs to the man for lunch.  "Neither of them did their job." he said.

This incident resulted in an $80,000 fine against the facility.  Further, this reinforces Raintree's poor Medicare rating.  Raintree received just one out of five stars according the Federal nursing home rating system.

Related Nursing Homes Abuse Blog Posts

Nursing Home Resident Chokes To Death On Dinner

The Truth Revealed: Nursing Home Tries To Cover-up Fact That Resident Choked To Death On Tuna Sandwich

What Is It Like To Live In A 1-Starred Nursing Home?

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Perhaps the biggest risk posed to nursing home residents with dementia or other cognitive deficits is something rarely discussed and almost never considered harmful---food.  Food products and the packaging food is presented in, present significant hazards to residents who have swallowing or chewing difficulties and those who are cognitively impaired.

The OC Register recently reported about an incident involving an elderly man with dementia at the Anaheim Crest Nursing Center who choked to death on a tuna sandwich.  The incident reportedly took place on September 9, 2008 following two other choking episodes on the same day.  The first episode involved the nursing home staff inadvertently giving solid food to the unnamed resident despite the fact that his care plan set forth that he was only to receive pureed food.   The second episode involved the man grabbing a sandwich from an unattended food cart.

A state investigation into the matter confirmed that the man choked to death on a tuna sandwich-- the third choking incident on the same day.  The investigation further confirmed that the staff at Anaheim Crest did not try to clear his throat, check him for aspiration or provide any emergency treatment prior to his death. 

The investigation comes after the nursing home initially claimed that the resident died of a heart attack. State investigators were tipped off as to the suspicious circumstances regarding the man's death after a coroner concluded the death was related to choking. 

As a result of the nursing home's failure to follow the man's care plan (requiring pureed foods) and the facilities failure to provide care following his choking, the facility has been fined $75,000.

Supervision Is The Key

Nothing can take the place of supervision.  In facilities with residents who have dementia and Alzheimer's patients, it is crucial the staff not only follow the residents dietary restrictions (pureed foods, no commercially packaged foods, ect.).  Staff must provide assistance to ensure safety and to assure that each resident is consuming adequate nutrition and fluids.

Web Resources Regarding Nursing Home Resident's Dietary Restrictions

Anaheim nursing home faces $75,000 fine in choking death, By TONY SAAVEDRA, THE ORANGE COUNTY REGISTER

Alzheimer's Caregivers Guide, TIPS FOR CARING FOR A PERSON WITH ALZHEIMER'S DISEASE

Nursing Homes Abuse Blog Entries On Food Safety

Man Chokes To Death While Left Unattended At Nursing Home

Nursing Home Resident Chokes To Death On Dinner

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The Centers for Medicare & Medicaid Services has fined The Crossings, a New York nursing home $13,300 for failing to provide emergency medical treatment to a choking resident.  The fine involves an October 15, 2007 incident where an 89-year-old woman was left unattended by a nurse as she ate her dinner.  

The nurse returned to the woman's room to find the woman with her mouth open, not breathing and here lips were blue.  The nurse failed to call a 'code blue' to the situation and woman died.  A 'code blue' alerts the nursing home staff to a dangerous situation and summons them to help with medical assistance.  Code blue's also instruct the nursing home staff to call 911.

An investigation into the incident demonstrated the nursing home staff lacked training on 'code blue' drills that resulted in potential harm to all residents of the facility.  Amazingly, this nursing home was not shut down immediately by nursing home inspectors.  

As we have discussed before in the Nursing Homes Abuse Blog, many of the errors made in nursing homes do not involve complicated medicine. Why a nursing home employee, or any person, for that matter would not pick up the phone to call 911 reaches far beyond an error into into criminal territory.  Read more about this situation involving nursing home abuse at a New York nursing home here.

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Glenwood Gardens, a California retirement community was fined $100,000 by the California Department of Public Health following the death a resident who choked to death on a ketchup packet in 2006.  The 84-year-old man lived at the facilities skilled nursing facility because he suffered from dementia and had breathing difficulties.  The ketchup packet was wedged in the back of the man's throat by a mortuary embalmer.  Investigators determined the staff at the facility were aware of the man's propensity to eat non-edible objects and failed to formulate a plan to prevent the man from ingesting the ketchup packet.  Read more about this incident involving nursing home neglect here.

What makes this incident particularly inexcusable is that it occurred at a facility that concentrates in providing skilled nursing care to Alzheimer's and dementia patients.  It is a common problem for Alzheimer's Had the facility taken the basic precaution of removing non-edible objects from the residents meal tray this incident would likely not have occurred.  Moreover, had the staff properly monitored this man as he ate, the choking should have been caught and the ketchup packet removed from the man's throat.

Glenwood Gardens is part of Brookdale Senior Living communities.  Brookdale is the largest owner and operator of senior living communities in the United States.  Brookdale owns more than 550 senior living and retirement communities and houses more than 50,000 residents.  There are many Brookdale facilities throughout Illinois.

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A coroner determined that a 77-year-old nursing home resident choked to death on his dinner, according to an Australian newspaper. The victim suffered from advanced dementia necessitating assistance with meals. Investigators determined that the nursing home attendant assigned to supervise him left the man unattended as he was eating his dinner.

The link to the full article is here.

Choking injuries and asphyxiation are real dangers amongst the elderly. Many nursing home residents suffer from dementia, impaired judgment, difficulty swallowing, and problems chewing food. It is the responsibility of the nursing home staff to identify those who may be at risk for choking.

If a nursing home resident has difficulty swallowing, the nursing home staff should provide soft foods, cut all food into small pieces and make sure the resident is in an upright position while eating. Most importantly, the nursing home staff must carefully monitor residents during mealtimes to prevent choking. Choking incidents may result in injury, medical complications and even death.

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