4 Choking Deaths Reported At State Nursing Homes In 3 Months

A resident on a soft-food diet at the Lutheran Home in Southbury choked to death in April — the fourth choking death in a state nursing home over three months — after a nursing assistant failed to read the meal instructions and served the resident pieces of ham and a hard cookie, according to a state health inspection report.

The four deaths have prompted calls for more choking-prevention training for nurses and aides at convalescent homes.

Lutheran Home officials told state inspectors that they don't specifically instruct nurses' aides to check the special dietary orders before meals because that is supposed to be part of the aides' certification training. Contacted Monday, the home's administrator said staff members have now been re-educated about dietary protocols.

The Lutheran Home resident suffered from dementia and needed extensive help while eating. The dietary instructions called for ground meat, but the resident was served ham cut into half-inch pieces, according to the state Department of Public Health report.

The resident began coughing and choking during the meal, with a nurse's assistant sitting next to the resident, the report states.

Nurses moved the wheelchair-bound resident into a utility room and administered abdominal thrusts and the Heimlich Maneuver several times. The resident died before medics were able to reach the facility, the report states.

The assistant who served the meal later told inspectors that she "thought the resident was on a regular diet and was unaware the resident required ground meat," the report states.

The assistant admitted that she "did not check the diet slip prior to serving the meal," the inspectors reported.

The director and assistant director of nursing at the Lutheran Home told the health inspectors that nursing assistants aren't given in-service training about checking diet instructions before meals "because it should be part of the nurse's aide certification training," the report states.

The dietary aide who prepared the meal admitted that he knew the resident was on a soft-food diet but put a whole piece of ham on the plate because he "thought it was soft enough to eat," the report states.

After the resident's death, the dining-service manager acknowledged that the pieces of ham on the resident's plate were too big and that the hard cookie should not have been served, the inspectors reported. Ground meat was available at a steam table in the dining hall, the report states.

Todd Gaertner, the Lutheran Home administrator, said the dietary aide and the nurse's assistant were fired.

The state health department fined the Lutheran Home $615 out of a maximum $3,000 penalty. The department lacks the authority to issue significant fines but can revoke a center's license if corrective actions aren't taken.

In this case, the Lutheran Home's plan of correction was approved by the health department. Gaertner said the plan included the staff re-education.

The resident was the fourth nursing-home patient in Connecticut to choke to death between early February and late April. Two of the four residents had intellectual disabilities and were also clients of the state Department of Developmental Services.


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4 Choking Deaths Reported At State Nursing Homes In 3 Months