Nurse allegedly left choking nursing home resident alone for 15-20 minutes

The Kentucky Attorney General's office is reviewing the 2010 death of a resident of a Carlisle nursing home in which a nurse allegedly left a resident who was choking alone for 15 to 20 minutes.

The Johnson Mathers Nursing Home in Carlisle received a Type A citation from the Cabinet for Health and Family Services' Office of Inspector General on May 10 regarding the incident. The censure indicates a resident's life or safety was endangered because of violations of state regulations.

The April 30, 2010, incident involved a resident who had been admitted to the facility 10 days before and was on a pureed diet. The resident had requested all necessary measures be taken to save the resident's life.

After the staff fed the resident an evening meal, a licensed practical nurse in the hallway heard the resident "gurgling," according to the citation.

The citation does not identify the resident's gender, but the LPN referred to the resident as "she."

When the nurse heard the gurgling sound, the nurse stepped into the resident's room and asked if she could clear the food from her throat. The resident shook her head "no."

The LPN left the resident alone without staff supervision and did not notify other staff members of the resident's condition, the citation said.

The LPN, who was not identified, took 15 to 20 minutes to clean a dirty suction machine, even though the facility had a lifesaving "crash" cart that was equipped with a clean suction machine, the citation said.

At 6:30 p.m., the LPN suctioned the patient, "but provided no relief to the resident's choking," the citation said. At about 6:45 p.m., the nurse went to the nurse's station, where a registered nurse and other staff members were gathered and said: "I think she's gone."

The resident had a faint pulse, and a registered nurse administered CPR, according to the citation. The resident was taken to a hospital emergency room, where she died. The death certificate listed the immediate cause of death as aspiration pneumonia, the citation said.

"The facility failed to have an effective system in place to ensure ... supervision to residents who are choking and who have requested CPR," the citation said.

In Kentucky, the Cabinet for Health and Family Services sends all serious citations to the Attorney General's Office of Medicaid Fraud and Abuse Control, where investigators can then decide to forward the case to local prosecutors.

In the Johnson Mathers case, "we have received the Type A citation and are reviewing it," Allison Martin, a spokeswoman for Attorney General Jack Conway, said Tuesday. "It is the policy of this office not to confirm or deny the existence of an investigation."

Johnson Mathers officials did not return two phone calls seeking comment.

The facility's application for a state license in May 2010 — the most recent one posted on the cabinet's Web site — said Johnson Mathers was owned by Johnson Mathers Healthcare.

The facility's Web site said the nursing home was sold to Thames, LLC in November 2010.

The Nicholas County facility had 104 beds, according to the application.

From 2007 to 2010, there were at least 22 deaths at long-term care facilities in Kentucky that resulted in Type A citations.