Inset: Carol Polifka (Riverview Funeral Home). Background: St. Vincent Medical Center in Bridgeport, Conn., where Carol Polifka allegedly died due to a hospital food mistake (Google Maps).
An 80-year-old Connecticut grandmother died due to a hospital food mistake, with nurses failing to follow postoperative "liquid diet" and "easy to chew" orders — giving her "regular" meal trays instead, a lawsuit says.
Shelton native Carol Polifka, who had lung cancer, went to St. Vincent's Medical Center in Bridgeport for a "robotic-assisted" right lower lobe wedge resection surgery with mediastinal lymph node sampling and bronchoscopy on Jan. 23, 2024, which went well and was completed without any complications, her family says.
It's what happened during Polifka's recovery that wound up taking her life, according to a legal complaint filed this month by her son.
"Nursing staff departed from the standard of care … by serving, and documenting as received, a 'regular' diet on at least two separate shifts, in direct violation of the active SLP-ordered dysphagia level 7/mildly thick liquid diet and in the absence of any physician order upgrading the diet to regular," the complaint says, citing an opinion letter from a "licensed registered nurse" with more than 25 years of experience who reviewed Polifka's case.
"It is my opinion to a reasonable degree of nursing certainty and professional probability that there is evidence of medical negligence on the part of the nursing staff," the letter states, per the complaint.
After the surgery, Polifka's diet was supposed to consist of "easy to chew" foods and "mildly thick liquids," as ordered and implemented by a Speech-Language Pathologist (SLP) on Jan. 27, 2024, who mandated a "modified-consistency" diet and "specific aspiration precautions," according to the complaint.
"Decedent's medical history and clinical condition placed her at known and elevated risk for aspiration, including but not limited to: age 80; moderate-to-severe chronic obstructive pulmonary disease with chronic CO2 retention; recent postoperative state; post-anesthetic hypercapnic encephalopathy with documented BiPAP use on postoperative day zero and postoperative day one; morbid obesity; documented postoperative cognitive fluctuation; and altered mentation," the complaint says.
Before the SLP was consulted on Jan. 27, 2024, nurses inexplicably advanced Polifka's diet to "clear liquids" and then to a "cardiac (solid consistency) diet at lunch" on Jan. 23, 2024, without performing a bedside dysphagia screen or requesting an SLP consultation, according to the complaint.
When the SLP finally performed a "bedside clinical swallow evaluation" and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) on Jan. 27, 2024, they "confirmed pharyngeal dysphagia with airway compromise to thin liquids" and a "high likelihood of aspiration along posterior tracheal wall with thin liquids," per the complaint.
This meant that Polifka allegedly had trouble swallowing and was prone to getting food stuck in her mouth or throat, which she could choke on or inhale into her lungs, otherwise known as going "down the wrong pipe."
The SLP ordered the formal diet of "dysphagia level 7 solids (easy to chew) and mildly thick liquids," along with "1:1 supervision" and "small bolus size, slow rate of intake, upright positioning, monitoring for cough or change in vocal quality, cessation of eating at signs of fatigue, and oral care," per the complaint.
With the order in place, nurses allegedly served Polifka a "regular" diet on Jan. 29, 2024, while failing to "inspect, verify, and confirm that each meal tray delivered to [Polifka's] bedside matched the active diet order."
The nursing staff also failed to "implement and enforce" the specific aspiration precautions that were ordered, including "1:1 supervision at meals, small bolus size, slow rate of intake, upright positioning during and after eating, and monitoring for cough or change in vocal quality," according to the complaint.
"No physician order upgrading her to regular diet was entered," the complaint insists.
On the morning of Jan. 30, 2024, a respiratory therapist allegedly attempted naso-tracheal suctioning and documented "copious amounts" of vomiting by Polifka "into her airway."
Later that same day, Polifka experienced a "second vomiting event," per the complaint. She developed "worsening hypoxic and hypercapnic respiratory failure, went into PEA cardiac arrest, and was pronounced dead," the document says.
"Respiratory culture grew E. coli, an enteric organism diagnostic of aspirated gastric contents," according to the nurse's opinion letter. "The ICU admitting physician's note recorded the admission diagnosis as 'acute on chronic hypercapnic respiratory failure secondary to aspiration pneumonia.'"
The Connecticut Medical Examiner certified Polifka's cause of death as "infectious complications of right lung wedge resection with lymph node dissection for treatment of adenocarcinoma of the lung" and marked the manner of death as "therapeutic complications," according to the complaint.
Attorney Patrick Filan, who represents Polifka's family, told the Hartford Courant newspaper that the biggest tragedy of all this is that "she had a good outcome" from the surgery she underwent. Her lesion was reclassified as "adenosquamous carcinoma" and the "margins were negative," meaning the removed lung tissue had a border of completely healthy tissue with no cancer cells left at the edges.
"It's not a case where the operation went wrong, it is basic postoperative attention to detail where she was let down," Filan said. "Elderly [patients] are very reliant on hospital staff. Sadly, they let her down."
A spokesperson for Hartford Healthcare, which operates St. Vincent's Medical Center, told the Courant, "Our heartfelt thoughts and deepest sympathies are with the family at this time. We are unable to provide further comment on pending litigation."