GREAT BARRINGTON — A resident of a nursing home who required close monitoring while eating choked to death last year after being left alone in their wheelchair to eat dinner.
A certified nursing aide left the room after bringing a meal of French toast and a sandwich to the resident at Fairview Commons Nursing and Rehabilitation Center off Christian Hill Road, according to a federal report. The resident was not allowed to have dry bread due to a severe case of a condition called dysphagia, which delays or disrupts swallowing.
The neglect resulted in a fine of $88,218, according to a June 2022 inspection report from the Centers for Medicare and Medicaid Services.
The exact date of the incident, as well as all other identifying information, was redacted to protect the resident’s privacy.
A more general investigation by the state also revealed a failure by the facility to maintain complete and accurate medical records, as well as not documenting daily routine care, leaving those charts “blank.”
In a statement from Integritus Healthcare, which owns the facility, Fairview Commons reported the incident to the state Department of Public Health within two hours. The facility also began an immediate investigation, a plan of correction and started “re-education and training” for staff, particularly around feeding plans and tray orders.
The staffer who left the resident alone worked for a staffing agency and was not an employee of Fairview, wrote Lisa Gaudet, vice president of business development and marketing for Integritus.
It appears there was no criminal investigation or charges against the staffer, according to Gaudet as well as Great Barrington Police Chief Paul Storti. The Berkshire District Attorney’s Office had no knowledge of an investigation. Storti told The Eagle that the department had not received any calls about the incident.
The resident apparently was making some of their own choices about eating. “The resident had self-determination around food choices and dining locations,” Gaudet wrote.
“We are saddened by the event and continue to extend our sincere sympathy to the family on the loss of their loved one, who was a dearly loved member of the Fairview Commons family of residents,” Gaudet said.
The facility has been fined nearly $147,000 since mid-2020. These include penalties for an incidence of physical and emotional abuse.
It also been cited for more than 66 violations since 2016 — only second in Berkshire County to Integritus’ Hillcrest Commons in Pittsfield, which has received the most citations since that year. Hillcrest is also the largest nursing home in the county.
‘Gasping for air’
According to the inspection report, the aide brought the meal of “diced-up bologna mixed with mayonnaise served on two slices of white bread that was cut in half and some French toast that was cut up into various sizes” to the resident in the lounge of that resident’s unit. Before she left the room, she told the resident to “take small bites and chew because she knew he/she would eat fast and would take big bites.”
“CNA #1 said after she finished setting up Resident #1 to eat, she left the Unit Lounge, and said there were no other staff members in there to provide supervision to him/her while he/she eat,” the report says. “CNA #1 said she was aware that Resident #1 required supervision with his/her meals but said she did not provide Resident #1 with supervision during his/her evening meal.” She later told investigators that she was not aware of the need for close monitoring during meals.
About 45 minutes later, another aide was walking down the hallway and looked in the unit lounge. She saw the resident seated in the wheelchair “with his/her head up against the wall and his/her mouth was hanging open.”
She ran into the unit, pulled a piece of food out of the resident’s mouth and called for the aide who had left. She arrived to help.
The resident was unresponsive and “gasping for air” while staff tried to resuscitate them. They removed more food from the resident, “who did not have a palpable pulse.” The resident was taken to the hospital by ambulance and died sometime after.
The second aide told investigators that “there were no staff members present when she found Resident #1 unsupervised in the Unit Lounge.” She also said she knew the resident could not eat alone and didn’t know why they were left alone.
The resident, who was admitted to Fairview in 2020, had experienced choking and coughing with meals. Medical consultations indicated they should not eat “dry bread,” that he/she required extra time during meals, effortful swallowing, monitoring of his/her oral intake rate, and he/she should be positioned upright.”
Hillcrest Commons in Pittsfield was fined nearly $115,000 in 2021 for allowing a resident to repeatedly bang their head on a table, causing their death.