A Minnesota nursing home resident was served solid food in violation of doctor's orders, leading to him choking to death despite immediate efforts to free the lodged tuna sandwich, according to results of a state Health Department investigation released this week.
The home, part of the Mahnomen Health Center, was found negligent in serving the sandwich to the resident, identified by the family as Keith H. Johnson, 82, of Mahnomen, even though his doctor's instructions called for him to eat only pureed food because of his history of eating too fast and choking.
In response to the state's determination, the nursing home's director of nursing, Rachel Tuenge, declined Thursday to address specifics, only saying: "We regret the tragic incident that occurred. We investigated the incident fully on the day it happened and made the necessary changes in our policies."
According to the state's findings:
Johnson, who suffered from Alzheimer's, and other residents were served a snack on Dec. 13, 2010, and left unsupervised. One employee noticed that he was trying to cough, and was unresponsive and not breathing. Two attempts to restore his breathing with the Heimlich maneuver failed.
Johnson was hospitalized and died six days later from lack of oxygen to the brain and cardiac arrest.
The state blamed the nursing home for Johnson's death because it failed to instruct staff members about his dietary requirements. Investigators also noted the home provided little or no supervision for residents who are at risk of choking.
One staff member connected to the incident explained that she had seen Johnson in earlier instances eating other solids -- namely cookies and bread -- "so she thought the resident could eat regular consistency food," the report read.
In response to the death, the home improved its supervision of residents who are at risk of choking while eating and educated staff members about the proper food consistencies.
Paul Walsh • 612-673-4482