State officials have cited an assisted living and rehabilitation center in Huntley after they say staff error allegedly caused a patient’s death from choking on food.
The Illinois Department of Public Health (IDPH) cited Alden Estates of Huntley, located at 12140 Regency Parkway in Huntley, with a “AA” violation.
A report from the investigation said the facility failed to provide one-to-one supervision and implement doctor’s orders regarding a resident’s diet during meal times.
The resident, who suffered from Parkinson’s disease, dementia and other conditions, experienced a choking episode on September 19.
He began choking during dinner time but was able to remove all the food.
He was examined and a nurse practitioner ordered him to be fed a mechanical soft diet until speech therapy could evaluate him the next day, the report said.
He was also ordered to be fed with one-to-one supervision by nursing staff at a slow rate.
One-to-one feeding means staff are sitting with the resident, who is at high risk for swallowing difficulties, and providing constant and close supervision.
The next day, the resident was in the dining room eating breakfast when he began coughing, the report said. Staff reported he turned blue and looked lifeless.
Staff began performing the Heimlich maneuver and other measures before calling 911 after taking him to his room.
Paramedics transported the man to a hospital and he was later pronounced dead.
His cause of death was complications from aspiration pneumonia from choking on food.
The state report, which includes interviews with staff, said there was no one-to-one supervision being provided to the resident while he was eating.
“There were no staff members near him when we ran into the dining room so there couldn’t have been anyone providing 1:1 assistance. I didn’t know there had been a choking incident the night before or that he needed a downgraded diet or 1:1 supervision,” a licensed practical nurse said in an interview.
“This is the first I’m hearing about this as it was never provided to me in nursing report. That is a significant event that should have been reported to me so that I could monitor him closely and make sure the correct interventions were implemented,” the nurse said.
A certified nursing assistant was the first one to find the resident choking after another resident yelled for help.
“So I ran into the dining room and began patting [the resident’s] back and at first, he wasn’t breathing. I kind of froze and didn’t know what else to do other than pat his back so I yelled for the nurse,” the nursing assistant said in an interview.
The nursing assistant said they were “shocked” that no one was in the room supervising any of the residents at the time.
The report said that the nurse practitioners’ orders from the prior day were never entered into the system or communicated to the oncoming nurse that day.
IDPH officials noted that Alden Estates was unable to provide a policy regarding the supervision of residents at meal times as of October 17 — nearly a month after the resident died.
An “AA” violation, which is what the health department cited the facility for, is when an incident occurs that proximately causes a resident’s death. Alden Estates of Huntley was fined $50,000 for the violation.
Four other facilities in Illinois were also cited with “AA” violations during the first quarter of this year, including nursing homes in Palos Hills, Cicero and Danville.