|November 12, 2002
GIFFORD FACILITY FINED FOLLOWING RESIDENTS' DEATHS
SPRINGFIELD, IL The Illinois Department of Public Health has fined Country Health $20,000 (Statement of Violation), for failure to provide dining room supervision to prevent choking incidents. The 89-bed skilled and intermediate care facility is located at 2304 CR 3000 North in Gifford.
Responding to complaints, the Department learned two residents died within hours of each other after choking on food.
The first resident died during breakfast after a prune lodged in her throat. The resident, who in the past month had choked on prunes, was not to be given whole fruit and was to be supervised at meal time. An employee, who was aware of the resident's dietary restrictions, observed the resident eating prunes and moved the fruit bowl away, but not out of her reach.
The restriction on fruit was not noted in the resident's care plan and some employees said they were unaware of the previous choking incident.
At lunch, another resident was found slumped over in a wheelchair after choking on a piece of sausage. The resident was under a physician's order to have her food cut into small pieces and to be supervised while eating, but that information was not included in the resident's care plan and staff said they were unaware of her special needs. At the time of the incident, the resident was in area of the dining room where there was no continuous staff supervision.
In both instances, emergency procedures were not started until the residents had been removed from the dining area. Staff said they discontinued emergency care because both women had "Do Not Resuscitate" orders.
The Department-ordered plan of correction required the facility to assess residents to determine their risk of choking, to immediately report possible choking problems to the charge nurse and to perform a regular audit of tray cards to assure that residents are receiving food as ordered.
Country Health has requested a hearing on the Department's action. No hearing date has been scheduled.
of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
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