Staff members at an assisted-living facility in Crystal went against physician's orders and served a salad to a resident, leading to him choking on a large cherry tomato and dying less than 30 minutes later, according to a state report released Tuesday.
The report into the man's death on Sept. 13, 2010, at Heathers Manor determined that the facility failed to ensure that staff members followed the resident's dietary guidelines when he was given the salad.
At the time of his death, he was limited to foods and liquids that reduce the risk of choking, according to the state report. Raw vegetables and salads were forbidden. He liked salads, ordered his own meals and fed himself, the report noted.
The resident, who came to Heathers Manor about two years earlier after a stroke and onset of dementia, "was not being provided the correct diet as ordered by his physician and [began] choking while eating supper" about 4:40 p.m. He died 27 minutes later, after staff and then emergency personnel attempted to revive him, the report said.
Paramedics noticed a large cherry tomato had been removed from his mouth, and that is what made him choke, according to the report.
The man's diet was made more strict in June and again in July. Even so, according to the investigation, "dietary staff did not follow [the guidelines]" and allowed the resident "to continue ordering and eating salads."
In response to the death, a state order was issued against the facility. The Health Department said last month that Heathers Manor has taken the proper corrective measures.
Telephone messages seeking comment on the report were left Tuesday afternoon at the offices of Heathers Manor and its parent company, Transition Healthcare in St. Louis Park.
