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Choking Death

Published on October 3rd, 2017

St. Louis Today reported the tragic death of a nursing home resident who choked and died in July after the patient was fed through a tube in 30 minutes instead of the one hour that was prescribed, according to a federal report.  Then a nurse failed to check on the patient, perform CPR and call 911, as required by the patient’s medical record and the nursing home’s policies, investigators with the U.S. Centers for Medicare and Medicaid Services found during an August inspection. The home was cited for placing residents in immediate jeopardy and could be fined for the incident.

A doctor at the nursing home told investigators that the formula coming out of the patient’s nose and mouth at the time of death indicated that he or she choked on the food and suffocated.

Because of the patient’s risk for choking, the formula tube feeding was supposed to be infused over one hour with supervision. At a 4 a.m. feeding on July 23, the nurse infused the formula through the tube in 30 minutes and left the patient after checking vital signs. One hour later, a nursing aide checked on the patient and couldn’t find a pulse. The aide called the nurse, who tried and failed to take the patient’s blood pressure and also could not locate a pulse, according to investigators’ interviews with the staff.

 The nurse then looked at the medical records and realized that CPR should have been performed and 911 called. In the report, investigators wrote “during that shift, Nurse A was very overwhelmed with trying to learn the facility procedures and there were no other nurses on duty to answer his/her questions … Nurse A knew what was expected of him/her and there was no excuse for failing to follow proper procedure.”

 

 

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