Patient with swallowing disorder chokes to death at Conn. nursing home

A nurse briefly left a dinner tray unattended; medication and treatment records did not reflect the patient’s diagnosis of dysphagia

By Josh Kovner
The Hartford Courant

DANBURY, Conn. — A patient with a swallowing disorder choked on a meatball after a nurse briefly left a dinner tray unattended at the Danbury Health Care Center in January, the state Department of Public Health reported Monday morning.

The facility was fined $1,040, out of a maximum state fine of $3,000, and ordered to submit a plan of correction.

The patient was transported by ambulance to a hospital on Jan. 27 and was pronounced dead the following day, according to DPH records. The cause of death was listed as aspiration leading to hypoxic encephalopathy — a lack of oxygen to the brain. A seizure disorder and laryngeal cancer were noted as underlying causes.

Choking deaths in nursing homes have been the subject of increased training and safety bulletins from the Office of Protection and Advocacy for Persons With Disabilities for the last 12 years – but the incidents still occur. There were concentrations of choking deaths in the middle of the last decade and in 2012.

DPH inspectors said the Danbury patient’s medication and treatment records did not reflect the patient’s diagnosis of dysphagia — difficulty in swallowing — and risk of aspiration.

At 5:40 p.m. on Jan. 27, a licensed practical nurse placed the evening meal tray on a bedside table in front of the resident. The nurse did not uncover the entree or set up the tray, the DPH inspection report states.

The nurse “returned to the medication cart outside (the resident’s) room to prepare the resident’s evening medications. Upon return to the room, the (resident) was lying on the bed, unresponsive,” the inspectors reported.

At the hospital, a meatball was removed from the patient’s airway, the report states.

The meatball was three-quarters to one-inch in diameter, the DPH inspectors said.

The Danbury center’s food-service director told investigators that the kitchen staff wasn’t responsible for cutting up meatballs. The resident’s diet plan included cut-up meats.

The nurse who served the meal acknowledged “that the problem of dysphagia should have been recorded on the eating and nutrition section of the resident evaluation form,” the DPH report said.

Between February and December 2012, at least five patients died as a result of choking incidents at Connecticut nursing homes.

 On April 29, 2012, a patient on a soft-food diet choked to death on take-out ziti and meatballs delivered directly to the patient’s room at the Meridian Manor nursing home in Waterbury, according to DPH records.

McClatchy-Tribune News Service

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