Choking in Nursing Homes
Elderly adults face a high risk of choking. Nursing homes owe patients a duty to detect conditions that could contribute to their choking risks and take proactive measures to prevent this from happening.
Choking is the second-highest cause of preventable death among older adults in care facilities, according to a study published by the National Institute of Health. Although choking is typically associated with young children, studies have found that people over 65 are seven times more likely to choke than children ages 1 to 4.
During the period from 2007 to 2010, as many as 2,214 elderly individuals died from food-related choking, with the strongest correlations to dementia, Parkinson’s disease and pneumonitis. In light of these findings, nursing homes owe patients a duty of care to take proactive measures to prevent choking.
Why are older adults more likely to choke?
Aging individuals experience changes that make the process of eating and swallowing more challenging. Difficulty swallowing is known as dysphagia. Reductions in muscle mass and strength throughout the body, including muscles that are critical to swallowing, contribute to this condition. Other contributing factors include:
- Loss of teeth
- Changes in the structures of the throat
- Reductions in tongue force and swallowing reflexes
- Health conditions that impact cognitive function
Certain conditions also predispose aging individuals to dysphagia. These include but are not limited to the following:
- Parkinson’s disease
How prevalent is dysphagia?
Studies have reported that 25 to 70 percent of nursing home patients suffer from this condition. Nursing home patients coping with dysphagia may experience a reluctance to eat due to their fear of choking or aspiration. If this is unaddressed, these patients could become malnourished or dehydrated.
Screening for Dysphagia
It is important for nursing homes to screen residents for dysphagia and develop a feeding program that will address the patient’s nutritional needs and prevent choking and aspiration. According to the American Speech-Language-Hearing Association (ASHA), nursing homes have multiple non-invasive screening options available, including the following:
- Medical history review
- Cough assessment
- Gag reflex evaluation
- Water swallow tests
- Planned trial swallows
- Assessment of the laryngeal cough reflex
- Various standardized swallowing screening tests
A study by ScienceDirect found that dysphagia screening is not commonly practiced in nursing homes, despite its commonality and repercussions. If dysphasia is not screened for and detected, patients are not receiving the care they need. This could explain why nursing home patients commonly experience malnutrition and dehydration.
Choking and Aspiration
Choking and aspiration are two separate effects of dysphagia. The University of Massachusetts defines them as follows:
- Choking: Food becomes lodged in the airway and blocks airflow
- Aspiration: Food or liquids enter the airway without blocking it, potentially ending up in the lungs.
Risk factors for choking and aspiration, which nursing home staff should watch for closely during meal times, include the following:
- Food textures – Some foods present a higher risk of choking or aspiration than others
- Patients eating too fast or not chewing adequately, or being rushed by the staff
- Patient distractions during meal times
- Poor airway protection
- Poor coordination of breathing and swallowing
- Guzzling liquids and gulping air
How can nursing home personnel prevent choking and aspiration?
Screening for dysphagia should be a routine procedure for all nursing home patients. According to HealthLink BC, a Canadian health care information service, the nursing home should develop a care plan that addresses the feeding needs of the patient. All members of the care team should participate, including direct care staff and family members that participate in feeding the patient.
The care plan should address the following:
- Food textures
- The type of diet
- The thickness of liquids
- The seating position
- Adapted eating and what feeding aids and utensils should be used
- Oral care plans
- The need for assistance or supervision during meal times
Any staff involved in the supervision or feeding of the patient should be certified in first aid, CPR and feeding techniques. During meal times, the following precautions should be observed:
- Observe the facility’s choking response protocol
- Use only foods and utensils that match the care plan with no exceptions
- Ensure dentures are properly affixed during meal times
- Never leave the resident without supervision while eating
- Avoid distractions such as television during meals
- Ensure the patient is awake, alert and sitting up straight throughout meals
- When necessary, remind the patient to swallow, slow down or continue
- Never force-feed or rush the patient to swallow or finish a meal
- Report difficulties to the health care team
Nursing homes are chronically understaffed, which can cause overburdened staff to neglect or ignore a feeding plan. This can be a fatal error. Choking can result in immediate death. Aspiration can lead to pneumonia and ultimately death. Even when these incidents do not result in death, patients who choke or aspirate face a heightened likelihood of recurrence.
Why do nursing homes allow patients to choke?
Choking deaths are preventable, but nursing homes are clearly not doing enough to prevent these untimely deaths. They are not routinely screening patients for dysphagia, which means patients with dysphagia are not being offered care plans. This indicates patients are not receiving the supervision or assistance they need.
In addition to inadequate staffing, nursing homes too often fail to provide adequate training to direct care staff, which are most often CNAs. Even if patients do have a care plan that includes a feeding plan, CNAs who are not trained in feeding techniques may be tasked with this responsibility. This can be a deadly mistake.
In addition to being poorly trained, CNAs are often overworked. Both of these factors can pressure CNAs to rush meals, force-feed patients, end meals before patients have finished, leave patients without supervision and cause meal times to be unpleasant for patients. Even if they try to allow the patient time to finish, supervisory staff may compel them to rush the meal.
Holding Nursing Homes Accountable for Choking Injuries and Deaths
Nursing homes are responsible for the well-being of their patients. Failure to detect dysphagia or other risk factors for choking does not absolve nursing homes of their responsibility when patients experience injuries or death as a result of choking while under nursing home care.
If your family member has been abused or neglected as a patient of a nursing home, you have the right to hold the nursing home accountable. Contact us today for a free consultation.
Dr. Patricia Shelton, MD
Dr. Patricia Shelton, MD, is a medical content creator. She holds a Doctor of Medicine degree and a Bachelors degree in neuroscience, both from the University of Washington in Seattle. Her career is now focused around medical communications. She primarily writes content for health-related websites, but has also written test prep materials, white papers, court documents, and more. She also teaches anatomy and physiology at the college level for the National Institutes of Health, as well as at the general public level in yoga teacher training programs. Her book, The Yoga Doctor, was published in 2015.