Case Types
Choking
Choking is an unimaginably painful way to die.
Nursing home residents should never choke or suffocate. Choking deaths in nursing homes are always preventable. Unfortunately, it occurs much more often than most people can imagine. Choking continues to be a leading cause of death in nursing homes.
Choking Is A Sign of Neglect and Abuse
No one in a nursing home should ever die from choking. Choking in nursing homes is preventable with appropriate care. Nursing homes are required by law to provide a safe environment for every resident at all times. If a nursing home resident chokes, then they were denied their right to a safe environment.
Nursing homes must provide residents with foods they can safely eat. Nursing homes must also monitor residents while they are eating to make sure that they do not choke.
Many residents who are at risk of choking have very specific dietary protocols in place to protect their airway. Those orders are typically created by a swallowing specialist called a speech language pathologist or a doctor. Those may include a special diet where the texture of the food is nearly liquified or having someone physically assist the resident to prevent them from taking too large of bites or swallowing before the food is fully chewed. Whatever orders are in place, the nursing home must follow them. If the nursing home does not follow these orders, it is considered neglect and abuse.
It is also the nursing home’s job to be on the lookout for any signs of choking, gasping, coughing or difficulty swallowing. If the resident displays any of these concerns, the nursing home must report these concerns to the appropriate specialist. If the nursing home ignores these concerns, that is also considered neglect and abuse.
Although choking is preventable, it remains one of the leading causes of death in nursing homes. Why? The primary reason that residents choke in nursing homes is because of failed leadership and a culture that allows neglect to become the norm. Those leadership failures often result in understaffed facilities where there simply are too few nurses and aides to monitor patients while they are eating, a rushed dietary staff that accidentally sends the wrong food to the resident, poorly trained staff because management is more focused on providing care that can be billed to insurance than on training staff, unenforced policies and procedures, and not even having foods that are safe to eat because of budget restrictions.
Who Is at Risk for Choking in Nursing Homes?
Any person who has difficulty swallowing is at risk for choking. The medical term for having difficulty swallowing is “dysphagia.” Many, if not most, nursing home residents are at some risk of choking.
Choking is the fourth leading cause of unintentional, preventable death. More than half of those people who die from choking are elderly.
Because elderly people are at a higher risk of choking and nursing homes are both legally and morally obligated to protect their residents, no one should choke to death in a nursing home.
What Conditions Put Nursing Home Residents at Risk for Choking?
Psychiatric Disorders
Many psychiatric disorders increase the risk of choking for two reasons.
First the disorder itself can make a person susceptible to choking.
Schizophrenia, for example, can result in a form of eating called “wolfing” or “scarfing” where the person takes too big of bites of food too quickly and attempts to swallow the food before fully chewing. This often stems from a lack of impulse control and also because many individuals with psychiatric disorders get more pleasure from eating than individuals without those conditions.
Second, long term use of antipsychotic medications can cause difficulty swallowing. Many studies have shown that haloperidol, loxapine, trifluoperazine, olanzapine, risperidone, quetiapine, clozapine, and aripiprazole are also associated with increased choking risks.
Many nursing home residents have a history of psychiatric conditions or of psychiatric medication use.
Alzheimer’s Disease
Alzheimer’s disease accounts for 60-70% of all cases of dementia. 84-93% of all Alzheimer’s patients are at risk of choking because of difficulty swallowing. That means that nearly all nursing home residents with a diagnosis of Alzheimer’s dementia are at risk of choking without appropriate care.
Neurological Disorders
The swallowing process is controlled by a series of complex nerves and muscles. Some neurological conditions can affect the muscles and nerves that are responsible for chewing, swallowing, and ensuring that food enters the esophagus (part of the digestive tract) and not the trachea (part of the respiratory tract).
Neurological disorders like Parkinson’s, multiple sclerosis, cerebral palsy, or muscular dystrophy can all affect a person’s ability to safely swallow.
Stroke and Other Brain Injuries
The brain controls the muscles and nerves that make swallowing possible. When the brain is injured following a traumatic brain injury, stroke, or certain cancers, the brain may no longer be able to provide the necessary signals to the body to safely swallow–or even swallow at all.
Dementia
Dementia is not a specific disease but is rather a general term for having difficulty remembering, thinking, or making decisions that interfere with day-to-day life. Years ago, nearly all types of psychiatric conditions were referred to as dementia. Today, dementia is typically restricted to vascular dementia, alcoholic dementia, Alzheimer’s dementia, or Lewy-body dementia.
As we age, the risk of dementia increases. In 2022, Columbia University researchers found that almost 10% of U.S. adults over the age of 65 have dementia and another 22% have mild cognitive impairment. At 90 years and above, more than 35% of people had dementia.
According to Harvard University researchers, around 750,000 nursing home residents have a diagnosis of dementia. That accounts for 50% of all nursing home residents.
Dementia increases the risk of choking for a combination of reasons that include motor-sensory changes, difficulty sequencing (understand the order that steps must take place like chewing before swallowing), and reduce awareness of what items are safe to eat and what are not.
Injuries to the Mouth, Neck, or Throat
There are more than 50 pairs of muscles and nerves that control swallowing. Any injury, whether from a direct blow, surgery, or injury from intubation or mechanical ventilation can increase the risk of choking.
Cancer
Certain types of cancer can increase the risk of choking. Cancer of a person’s mouth, throat, and esophagus can all decrease the ability to safely swallow. Swallowing difficulties also occur after some cancer treatments including radiation, therapy, chemotherapy, or surgery.
Aging
As we age, these nerves and muscles often become weaker. Being elderly is a risk factor for choking.
Lack of Teeth
A lack of teeth can increase the risk of choking for a few reasons.
First, without teeth, or with missing teeth, it becomes very difficult to chew food enough to safely swallow it.
Second, there have been instances when nursing home resident’s dentures were not securely fitted to their mouths and they became lodged in their throats causing them to choke.
How Can Nursing Homes Prevent Choking Deaths?
Assess the Patient for Choking Risks
Nursing homes must assess patient’s for their risks of choking when they enter the facility. They must reassess the patient periodically to determine whether there have been any changes. Staff must also be on the lookout for any signs that a patient is having difficulty swallowing. If the resident is having any signs that swallowing is becoming more difficult, staff must report these changes to a speech pathologist or physician. If the nursing home fails to do any of these, that is considered neglect.
Medical Treatment and Therapy
Nursing home residents should receive tests to measure their ability to swallow. These tests may consist of the following:
- Bedside swallow evaluation during which a speech pathologist will ask you questions about your swallowing, whether and when you have trouble swallowing, your medical history, and whether you have heartburn, coughing, or other conditions that may cause difficulty swallowing
- Fiberoptic endoscopic evaluation of swallowing called FEES where a speech pathologist passes a thin, flexible instrument through the nose and views parts of the throat while you swallow
- Modified barium swallow (MBS) study where a special x-ray allows the radiologist or speech pathologist to determine whether liquid is traveling into the lungs (which it shouldn’t do)
- Pharyngeal manometry where a speech pathologist evaluates and compares pressures generated by the muscles when you swallow
These tests are intended to identify whether a nursing home resident is at risk for choking. They are also intended to provide treatment to prevent nursing home residents from choking.
Treatment for for trouble swallowing may include:
- Learning exercise that help coordinate swallowing muscles or stimulate nerves that trigger the swallowing reflex
- Therapy to improve muscle strength to allow safe swallowing
- Botox injections in certain muscles to improve swallowing
- Dilation to stretch or expand the wall of the esophagus to allow food to pass
- Medicines may be prescribed to treat swallowing difficulties. This is especially true if swallowing problems are caused by acid reflux like gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux disease (LPRD). These medications help reduce stomach acid entering the esophagus
- Surgery may be considered if there is something blocking the esophageal path (such as a tumor or diverticula)
- Changing diet is the most common solution for nursing home residents
Safe Diet Textures
A nursing home must provide a resident with food that is safe for that resident to eat.
The texture of food is important to prevent choking. Solid foods, like meat, can lodge in the throat if not fully chewed. Other foods clump into what is called a bolus that is swallowed. Imagine a piece of white bread moistened and then squeezed in your hands. That gooey texture is a bolus and is a choking hazard for someone with trouble swallowing.
There are several options to alter the texture of food to make it safer. One option is to chop or mince food into very small pieces. Another option is to “mechanically soften” foods. This is similar to grinding food. A final option is to order a pureed diet. Pureed food is similar in consistency to baby food. Because the food is almost a thickened liquid, the chances of choking on it are very low.
Knowing the Patient’s Needs
All staff must know every patient’s risks and every patient’s needs. That means that not only must staff assess the patient appropriately and create an adequate treatment plan, staff must know the patient and know what is needed to keep the patient safe.
This requires having enough staff to pay attention to the resident, having staff that are openly and honestly communicating about the resident, and staff that actually care about the resident.
Policies and Procedures for Choking
All nursing homes are required to have policies and procedures about diet and meal service. However, having a written policy is not enough. A policy does no good unless all staff know what it is and that it is being followed.
It is the nursing home’s job to (1) have written policies to prevent and respond to choking events, (2) train staff on those policies and procedures, and (3) have enough staff to carry out those policies and procedures. Unfortunately in our experience, this is rarely the case.
Protocols for Managing Choking Emergencies
When a person chokes, seconds are like minutes and minutes are like hours. Within minutes without oxygen, brain tissue begins to die. Nursing homes must have an emergency response team for choking events. That includes a rapid response to begin assessing the airway and beginning the heimlich maneuver while also mobilizing the crash cart, which includes machines for suctioning the airway and bags to push air into the lungs.
What are the Signs of a Swallowing Problem?
It’s important for nursing homes to be aware of subtle signs of swallowing problems.
- Repeatedly clearing the throat while eating
- Coughing during or after eating
- Holding food to the side of the mouth (called “pocketing”)
- Eating too fast or cramming food into the mouth (“scarfing” or “wolfing”)
- Grimace or painful expression when eating
- Drooling when eating
- Spitting out food
- Touching the upper chest or throat when eating
- Chewing over and over but not swallowing
- Unexpected weight loss
- Change in voice (wet or gurgly, hoarse)
- Sorting or playing with food
- Taking longer to eat
- Runny nose
- Watery eyes
What Are The Signs of Choking?
All of the following are choking signs and behaviors.
- Coughing or gagging
- Hand signals and panic
- Sudden inability to talk
- The natural response to choking is to grab the throat with one or both hands. This is the universal choking sign and a way of telling people around you that you are choking.
- Wheezing
- Passing out
- The skin may begin to turn blue. This is called “cyanosis.” This occurs after other choking signs and behaviors have occurred. It is caused by a lack of oxygen to the skin. This blue coloring to the skin will be seen earliest around the face, lips, and fingernail beds.
Not all of these signs will be present when a nursing home resident chokes. For example, a resident with dementia may not initially realize he is choking or may not have the ability to cough or gag.
Suffocation in Nursing Homes
Suffocation deaths in nursing homes are always preventable. Here are some common causes of suffocation in nursing homes:
- Entanglement often occurs when physically or mentally disabled residents get caught up in garments, restraints, bed linens, or their heads can get stuck in bed rails or similar devices
- Faulty or poorly maintained breathing equipment can result in patients not getting necessary oxygen. Or, breathing equipment can come unhooked or disconnected. If staff fail to respond in a timely manner, the resident can die from suffocation.
Suffocation is always preventable and always caused by nursing home abuse and neglect.
Aspiration and Aspiration Pneumonia
Aspiration is not actually choking, but choking events are commonly referred to as aspirating. It is not unusual for a person to choke and for their family to be told that they aspirated.
Aspiration occurs when something other than air enters the lungs. This is usually fluid or food. If a person aspirates a large amount of fluid or food in a short amount of time, they can lose the ability to breath and die as a result. This is closer to drowning than choking.
Although aspirating is different from choking, acute aspiration resulting in death at a nursing home is preventable with reasonable care.
Representative Cases
Ron
Ron was an 81-year-old resident of a nursing home in Dayton, Ohio. An aide walked into his room and saw that he was gagging. Rather than begin the heimlich or other life-saving measures, the aide handed him a bucket to vomit in and left the room. Ron continued to gag and cough alone in a futile effort to clear his airway. After several minutes, the aide returned to find him unresponsive in his bed. The aide had trouble locating a nurse because the on-duty nurse was in her car smoking. When nurses did come to his room, they attempted CPR. However, Ron was on an air mattress. An air mattress does not provide enough resistance to provide CPR. Nursing staff never moved him to the floor where meaningful CPR could be given and they continued to provide CPR on the air mattress. Staff then called for the “crash cart,” which is a medical cart that includes a bag to force air into the chest cavity and a suctioning machine to remove any debris or items blocking the airway. For several minutes, no one could find the crash cart because they did not know what it looked like or where it was located. When staff finally found the crash cart, the equipment was broken and inoperable. Staff was required to inspect the items daily, but this was not being done. Ron was dead by the time emergency medical providers arrived. This case is currently pending in Montgomery County, Ohio.
Roger
Roger was a 66-year-old resident of a nursing home in Cuyahoga Falls, Ohio. Roger had amyotrophic lateral sclerosis (ALS), also called Lou Gerhrig’s Disease. ALS is a degenerative disease that affects nerve cells in the brain and spinal cord. Roger was unable to breath on his own. He required a bipap breathing mask that circulated air into his respiratory system for him. He lost the ability to breathe, likely because the breathing apparatus became disconnected. Roger struggled to breath until he died in his room. The lawsuit settled for $1,500,000 in Summit County, Ohio.
Walter
Walter was a 56-year-old resident of a nursing home in Warren, Michigan. He choked on a meatball the size of a golf ball. He had no or reduced airflow for approximately 30 minutes before dying. The jury awarded $2,350,000.
Regina
Regina was an 84-year-old nursing home resident in Paducah, Kentucky. She had Parkinson’s disorder and required a soft diet because she was at risk of choking. The nursing home provided her with several foods that were unsafe to eat. The jury returned a verdict of $5,000,000.
Stephen
Stephen was a 69-year-old man with a history of schizophrenia and a traumatic brain injury. He was known to “scarf” or “wolf” his food. He would attempt to take large bites of food and quickly swallow it without chewing. He was seen by a speech therapist who recommended that staff closely monitor him when eating to make sure that he took small bites, chewed his food thoroughly, and then swallowed his food. Nursing staff did not follow the speech therapist’s recommendations. Stephen was given a tray of food to eat alone in his room. This was a common practice. When staff arrived in his room to retrieve his meal tray, he was unresponsive and covered in vomit after choking. Staff then waited 41 minutes to call 911. Stephen never recovered and died. The jury awarded $26,000,000 in Trumbull County, Ohio.
Philip
Philip was a 47-year-old man with Down Syndrome. People with Down Syndrome, like schizophrenia, often have a tendency to “scarf” or “wolf” food. Philip was allowed access to food he could not safely swallow, choked, and died. The case settled for $925,000 in Trumbull County, Ohio.
Thomas
Thomas was a 68-year-old man with a history of schizophrenia. He had a severe swallowing disorder and had been ordered to be on a pureed diet. A pureed diet is similar to the consistency of baby food. Staff was aware that he could not safely swallow whole food. Staff also knew that Thomas lacked the mental capacity to know what was safe to eat and what wasn’t. Staff allowed Thomas access to a food that was not pureed that he choked on. Thomas was taken to the hospital but never recovered. The case settled in Cuyahoga County, Ohio for $750,000.
Jane
A 42-year-old woman with multiple sclerosis in a Charles Town, West Virginia nursing home choked several times. She choked at least one prior time in the presence of family members who were visiting her. She was later given a meal that contained pieces of meat she could not safely swallow. She choked on the food causing a severe brain injury and her eventual death. The jury returned $1,500,000.
How Much is My Choking Death Case Worth?
Every case is unique and has to be evaluated on its specific facts. The only way to determine the value of your nursing home choking death case is to begin an investigation.
