Unsupervised Geriatric Patient Expires After Choking During Lunch


Legal Nurse ConsultantThis case involves a 92-year-old female patient with Alzheimer’s who was living in a long-term nursing facility. The patient was considered to be at high risk for aspiration and was always supervised during meals. While the patient was eating lunch, the supervising nurses changed shifts leaving the patient alone for a few minutes. While alone, the patient choked on her food. Nursing staff attempted revival but the woman eventually expired.

Question(s) For Expert Witness

  • 1. What are the standards of care while working with a patient who has dementia and is an aspiration risk?
  • 2. What precautions are in place to prevent an incident such as this?

Expert Witness Response E-005614

The standards for nutritional care and support of patients in a skilled nursing facility (SNF) are firmly set by CMS (Medicare). Patients’ care must be supervised by an admitting physician, and include an admission assessment by a registered dietitian, with dietary needs set at this point. If swallowing problems are perceived, a speech therapist must be brought in to evaluate the extent. All information gathered on admission must be evaluated by the physician and a plan of care developed by him/her and the nursing staff. Nursing is then charged with preventative measures to be instituted, such as fall prevention, supervised meals, etc. Any difficulties with swallowing noted by the dietitian, the speech therapist, or nursing staff should be brought to the physician’s attention. A change in method of nutrition might follow. A failure to bring this patient problem to the physician’s attention and to address it proactively is a nursing breach of duty. I have served as a legal nurse consultant and expert since 2016 and have consulted on a similar case involving an SNF and its nursing staff’s failure to correctly observe and report a problem with a feeding tube.

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