Nursing Homes Abuse Blog - By Jonathan Rosenfeld

I've come to accept that the physical responsibilities placed upon nursing home staff are completely unrealistic.  The desire of management and administrators to maximize the individual productivity of nursing home workers may appear to be an admirable proposition on paper--- yet, fails when it comes to providing quality care for patients. 

While an assembly line approach to staffing can yield increased productivity in an industrial setting, the technique is inappropriate in situations where--- heaven forbid, more individualized care is required.  While I regularly hear from nursing home staff how overwhelming their superiors expectations are of them, it frankly can be difficult to accurately quantify how such working conditions impact the patients.

A recent episode of blatant nursing home neglect, reported by WCCO in Minneapolis caught my attention, for both the tragic outcome of the situation, but also because a closer review of the circumstances highlights the dangers situations of under-staffing at nursing homes. 

Recognizing that they were short-staffed one evening, officials at Adams Health Care Center called a night nurse in early to assist with the distribution of meals to patients.  After distributing a meal tray to an elderly man and positioning him in his bed, the nurse went about to distribute the remaining trays to other patients.  Unfortunately, in her haste to complete her responsibilities, the nurse failed to abide by specific instructions set forth in the patient's medical chart.

With a history of pneumonia and breathing difficulties, staff had identified the man as being a higher risk for choking and implemented the precautionary measures such as:

• Verbally instructing the patient to swallow each bite two times
• Instructing the patient to eat slowly and regularly clear his throat
• Position the bed at a 90-degree angle while he was eating and lower to a 45-degree elevation following the meal to help with digestion

Shortly after the patient was left with his meal--- and without the safety protocols in place, he began coughing.  Shortly after nursing home staff were summoned to his assistance, his heart stopped.  An investigation into the incident concluded that the patient's death was related to his choking on food.

While an appropriate sanction is being considered by officials, this incident highlights the dangers posed to vulnerable nursing home patients when there is inadequate staffing levels in place at facilities to satisfy each patients care needs. 

As opposed to placing all responsibility for this episode of nursing home negligence on the back of the single employee who acted inappropriately, I hope that officials delve deeper into this incident and evaluate the number of staff members on duty at the time of this incident and the number of patients they were responsible for caring for.

Related Nursing Homes Abuse Blog Entries:

Class Action Lawsuit Alleges Golden Living Failed To Provide Adequate Staffing For Patients

Study Demonstrates Nursing Home Workers Earn Less Than Minimum Wage

Less Patients, Happier Staff, Healthier Patients. Research Shows Less May Actually Be More When It Comes To Patient Loads For Nurses

'Poor Judgment' To Blame For CNA's Failure To Implement Fall Precautions In Minnesota Nursing Home Death

Officials from the Illinois Department of Public Health have imposed a $2,200 fine against North Church Nursing & Rehab after the facility failed to properly supervise a patient at the facility at mealtime and the patient choked to death on her food.

The State Journal-Register reported that the investigation into the choking death was triggered by the Morgan County Coroner who was conducting an examination of the patient's body.

Nearly two years before this incident, the same facility (then known as Golden Moments Senior Care Center) a similar incident occurred at the facility when a patient who was to be on a pureed food diet, choked to death on a pieces of ham that were intentionally cut for him by staff at the facility.  That incident resulted in an original fine of $50,000 that was subsequently reduced to $32,500 after the facility appealed the sanction.

My take:

I can appreciate the different levels of facility culpability involved in the two choking incidents--- and hence the significantly different fines imposed.  Nonetheless, I find the similarities between these incidents occurring at the same facility within a relatively short period of time--- to be extremely concerning.

As a lawyer who has representing families in nursing home lawsuits involving patients who have choked on food, I seriously question why a facility should seemingly be let off the hook when they failed to learn their lessons just a short while before.  If nursing home fines are going have their intended effect of improving patient care, I would hope that regulators look at episodes such at this, with a more critical eye--- the second time around.

Related Nursing Homes Abuse Blog Entries:

Golden Moments Senior Care Center Continues To Accumulate Fines Related To Providing Poor Care To Its Patients

Failure To Follow Doctor's Orders Results In The Choking Death Of Hospital Patient

Nursing Home Blamed For Resident Choking To Death On Raw Cukes

Toothless Patient Chokes To Death After Nursing Home Staff Ignores Doctor's Order

Nursing Home Responsible For Choking Death Of Patient

A recently filed nursing home lawsuit alleges that the delay in providing treatment for a coking resident resulted in her death.  The suit files by the family of the deceased nursing home patient, claims that a nurse and other staff members at the Johnson Mathers Nursing Home were negligent in the the way they responded to a situation where there loved one was obviously choking.

According to both state inspection reports and news reports regarding the incident, the patient had swallowing problems which resulted in staff giving her a diet of pureed food.  It was during the feeding process that the patient began to choke on the pureed food. 

However, upon hearing a 'gurgling' sound from the patient--- a clear indication of her choking-- the nurse elected to clean a dirty suction machine as opposed to summoning a clean suction machine from an available on a nearby 'crash cart' at the facility.

A remarkable 15-20 minutes were apparently spent cleaning the dirty machine as the nursing home patient laid in her bed--- choking.  Further, during the choking situation, the nurse failed to notify other staff at the facility because she assumed that the patient was dead.

Currently, the nurse's license is under investigation.

Situations such as this, highlight the need for nursing home staff to provide extra care while feeding patients with swallowing difficulties.  Patients with swallowing difficulties typically require extra encouragement and patience on the staff's end in order to safely consume their meals. 

Given the fact that some patients with swallowing difficulties have problems with the muscles that control the swallowing process and may have diminished sensory perception, it is also important that staff who provide care have proper training about how to clear an airway when a patient begins choking.

Certainly, in the case of this Kentucky nursing home, it appears as though the nurse involved exercised some horrible judgment.  However, I would be curious as to the the training Johnson Mathers provided staff feeding patients who have swallowing difficulties as well as how many patients this nurse was responsible for caring for during this time period?

Related:

Failure to Follow Orders Results In Death Of Patient & Hefty Fine

Lawsuit filed against nursing home where resident choked to death, by Valerie Honeycutt Spears, Kentucky.com June 11, 2011

Elderly Patients Are At Higher Risk For Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs

Dysphagia In Nursing Home Patients May Contribute To Medical Complications Such As: Choking, Pneumonia Or Death

Barry Community Care Center is a 75-bed nursing home located in Barry, IL. On January 22, 2010, the Illinois Department of Public Health (IDPH) fined Barry Community Care Center $35,000 for violations in the area of policy and procedure. Even with this significant fine, Medicare rated the facility as a three-star or average nursing home facility, with only one health deficiency between February 2009 and April 2010.

This episode demonstrates that even well-regarded skilled nursing facilities can have very serious problems for patients. Barry Community Care Center’s single deficiency involved its failure to provide each resident the care and services required to achieve or maintain the highest quality of life possible, which resulted in immediate jeopardy to resident health or safety. 

This example serves to reinforce how important it is to thoroughly research a potential nursing home because looking at the total number of health deficiencies is not enough. Not all health deficiencies are equal with regard to the level of harm presented to residents. In this case, the facility’s deficiencies and violations were very serious, resulting in the choking death of one resident. (See other Nursing Homes Abuse Blog articles on choking)

A survey conducted by IDPH on November 25, 2009 revealed that Barry Community Care Center failed to provide adequate supervision to a resident during mealtime, which resulted in the resident choking on food. Then, the nursing home did not call 911 for another hour, which led to the resident’s death at the hospital later in the day. 

The resident was known to have impaired cognition and limited range of motion for neck, arm, and hand. The facility’s care plan for the resident required one person to physically assist and supervise with meals. 

On September 26, 2009 at 1:00 pm, the resident was found in her room with a half-full plate of food from lunch in front of her. The resident was having trouble breathing and her face was ashen. A Licensed Practical Nurse (LPN) was called to the resident’s room. The nurse increased the oxygen and encouraged resident to cough. The resident coughed out some food but became too weak to continue. At that point, the nurse began to suction the resident while another nurse called the physician and power of attorney (POA). When the POA arrived, she requested that the resident be sent to the emergency room (ER). 

The ambulance was called at 1:56 pm, almost one hour after the facility found her having trouble breathing and choking on her food. When the ambulance took the resident to the hospital at 2:27, the resident had a rapid pulse and was still having trouble breathing. When the ambulance arrived at the hospital at 2:41 pm, the resident was unresponsive, suffering from major respiratory distress. The resident died at the hospital with a diagnosis of aspiration pneumonia (inflammation of the lungs from breathing foreign matter into your lungs), atrial fibrillation (irregular, rapid heartbeat), hypertension (high blood pressure), Type 2 diabetes, and history of chronic obstructive pulmonary disease (COPD). (See “Elderly Patients Are At Higher Risk for Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs”)

The facility never should have left the resident alone with her food tray, especially because the resident’s care plan called for her to have someone assist her with eating and drinking. In addition, the staff knew that the resident had trouble eating her breakfast on the morning of her death. One of the nurses had to physically remove pieces of egg and toast from her mouth before returning the resident to her room. Furthermore, the nurse should have immediately called 911 when she found the resident choking on food and having difficulty breathing. 

The choking death of the resident at Barry Community Care Center is a sad reminder of how quickly a nursing home resident can suffer injury, or in this case, death, when they do not receive proper care and supervision. It took only 30 minutes for the resident to choke on food, when she should have had a staff member helping her eat, which would have prevented her death. 

Thanks to Heather Keil, J.D. for her assistance with this Nursing Homes Abuse Blog entry

Sources:

Illinois Department of Public Health: Nursing Homes in Illinois Quarterly Report

IDPH: Barry Community Care Center

IDPH: Barry Community Care Center - Quarterly Report

Nursing Homes Abuse Blog: Elderly Patients Are At Higher Risk for Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs

Nursing Homes Abuse Blog: Choking

Choking Death Just Latest Problem At California Nursing Home

Elderly nursing home residents are at increased risk for a variety of dangerous conditions, diseases, and injuries. Even mealtimes can be dangerous, especially if you suffer from dysphagia (difficulty swallowing). Dysphagia can lead to dangerous food obstructions, aspiration of food into the lungs, pneumonia, or other upper respiratory infections. 

People with dysphagia have difficulty swallowing and may be accompanied by pain. Dysphagia can vary in severity. If you suffer from only mild dysphagia, you might have to stop eating for a minute or two, especially if you do not chew your food well enough or eat too fast. However, severe dysphagia is a serious medical condition that could prevent you from consuming adequate calories, which can require medical attention or even a feeding tube.

The act of swallowing requires the coordination of about 50 pairs of muscles and nerves. When you swallow, your tongue pushes the food to the back of your throat (oropharynx), where muscle contractions move the food through your pharynx to the top of your esophagus, then past your windpipe into your esophagus, where sphincters (bands of muscles) open and close to let food into your stomach. [ – picture of throat] [– diagram showing the act of swallowing]

Symptoms of dysphagia include: not being able to swallow, pain when swallowing, feeling as if food is stuck in your throat or chest, drooling, hoarseness, throwing up food, heartburn, unexpected weight loss, and coughing or gagging when swallowing. 

Causes of dysphagia

Dysphagia can be caused by many different conditions that interfere with swallowing. Esophageal dysphagia is difficulty passing food down the esophagus. It gives the feeling of food being caught in your throat or chest. This can be caused by:

• Achalasia – the lower esophageal muscle does not relax properly to allow food to pass into your stomach
•  Aging – the esophagus loses muscle strength and coordination as you age
• Diffuse spasm – after you swallow, you experience multiple, high-pressure, poorly coordinated esophageal contractions
• Esophageal stricture – narrowing of the esophagus, which makes it easier for food to get caught
• Esophageal tumors
• Gastroesophageal reflux disease (GERD) – stomach acid backs up into your esophagus, which damages the tissue
• Eosinophilic esophagitis – overpopulation of cells in the esophagus
• Scleroderma – development of scar-like tissue, causing stiffening and hardening of tissues
• Radiation therapy – can lead to inflammation and scarring of the esophagus

Oropharyngeal dysphagia is difficulty emptying material from your oropharynx (back of the mouth) into the esophagus. It is caused by problems relating to your nerves and muscles which weaken your throat muscles, making it more difficult to swallow. This can be caused by:

• Neurological disorders – post-polio syndrome, multiple sclerosis (MS), muscular dystrophy, Parkinson’s disease
• Neurological damage – stroke, brain injury, or spinal cord injury can cause certain neurological damage
• Pharyngeal diverticula – a small pouch forms and collects food pieces in your throat
• Cancer

With some cases of dysphagia, there is no anatomical cause. This can present itself as difficulty taking oral medications or the sensation of a lump in your throat when no lump exists.

Consequences of untreated dyphagia

Severe dysphagia can lead to malnutrition and dehydration if you cannot eat enough food or drink enough liquids to stay healthy. Dysphagia can also lead to respiratory problems if food or liquid enters your airway. This can lead to respiratory problems and infections including pneumonia or upper respiratory infections (URIs). 

Treatment of dysphagia is usually directed at the specific cause. However, if complete obstruction occurs, a doctor will perform an emergent upper endoscopy to see inside the upper GI tract. The doctor can then treat any masses or lesions, or even remove an impacted food mass. A barium x-ray can also be performed to allow the doctor to see changes in your esophagus and assess your esophageal muscles. 

Some people who suffer from dysphagia benefit from changes in how they eat including changing head position, doing dry swallows, and doing strength and coordination exercises for the tongue. Some people with severe dysphagia require the use of a gastronomy tube in order to receive adequate nutrition. 

Older adults are particularly at risk for dysphagia

Dysphagia is more common in older adults because of decreased muscle strength, including the muscles in the esophagus. As many as 22% of adults over 50 years of age suffer from dysphagia. The esophagus suffers normal wear and tear as you age, which can make swallowing more difficult. Also, older adults are more likely to suffer from conditions (listed above) that can make swallowing difficult, including stroke, Parkinson’s disease, and cancer. Dysphagia can potentially compromise an elderly resident’s nutritional status, which increases the risk of aspiration pneumonia. 

Because older adults have an increased risk for dysphagia and choking, nursing home staff should take extra care to monitor residents, who have a history of problems swallowing, during mealtimes. Staff members should also take the time to supervise chewing and swallowing exercises to encourage residents to take small bites, focusing on chewing and swallowing. This requires a great deal of supervision by nursing home staff, which might be difficult when numerous residents have dysphagia or trouble swallowing. 

Dysphagia or difficulty swallowing can be a dangerous condition for elderly nursing home residents. This is because they often have weakened esophageal muscles, which makes choking more likely. It is important to notify nursing home staff if your family member has difficulty swallowing, so staff can closely monitor them during mealtimes. 

Special thanks to Heather Keil, J.D. for her assistance with this Nursing Homes Abuse Blog entry.

Sources:

Medicine Net: Dysphagia

National Institute on Deafness and Other Communication Disorders

American Family Physician: Evaluating Dysphagia

American Speech-Language-Hearing Association: Communication Facts: Special Populations: Dysphagia-2008 Edition

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.

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

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. 

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

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.