Negligence of Care Plan Results in Choking Death at Cranbrook Geriatric Village

A 59 year-old male died as a result of choking on food when nursing home staff neglected to assist him during meal time. This gentleman’s Care Plan clearly stated that he required the “visual supervision of at least one person during mealtime,” and that the person must be no more than one arm’s length away from him for physical intervention in case of choking.

This gentleman was admitted into Cranbrook Geriatric Village in Detroit, MI, on January 30, 2011.  He was diagnosed with schizophrenia and dysphagia (dysphagia is the partial inability to swallow.) Because of the swallowing problems, he required assistance and direct supervision during all of his meals. Despite knowing these facts, on April 7, 2012, he ate a meal alone in the dining room.  The nurse assigned to keep him safe was sitting at the nurse’s station. This gentleman approached the nurse’s station in distress and with breathing difficulties. The Heimlich maneuver was performed with no result. The staff moved this gentleman to his room, called EMS, and continued to perform the Heimlich maneuver, this time ejecting a small piece of sausage. Still, he continued to choke. When EMS arrived, they pronounced him dead on the scene.
Had this gentleman been assisted during his mealtimes like his Care Plan clearly required, he would not have choked on food and died minutes later. Staff negligence caused this gentleman’s premature death.