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).
A heartbreaking oversight at a Connecticut hospital has led to the tragic death of an 80-year-old grandmother. Despite clear postoperative instructions for a restricted diet, nurses at St. Vincent’s Medical Center in Bridgeport mistakenly provided Carol Polifka with regular meal trays, which ultimately cost her life. Her family is now seeking legal action.
Carol Polifka, a resident of Shelton battling lung cancer, had undergone what was initially a successful surgery on January 23, 2024. The procedure, a robotic-assisted right lower lobe wedge resection, was performed to address her condition and was completed without any immediate complications, as reported by her family.
The trouble began during her recovery phase. Her son has filed a lawsuit alleging negligence, highlighting that the nursing staff deviated from the necessary standard of care. Despite explicit orders for a “liquid diet” and “easy to chew” foods, the staff served her a “regular” diet on at least two occasions, contrary to the directives set by a Speech-Language Pathologist (SLP) days after her surgery.
The legal complaint, supported by a veteran nurse with over 25 years of experience who reviewed the case, asserts that the hospital staff failed to adhere to the prescribed dysphagia level 7/mildly thick liquid diet. This diet, crucial for someone in Polifka’s condition, was supposed to prevent aspiration risks, yet was inexplicably ignored without any physician’s order to do so.
“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 nurse’s letter, included in the complaint, declares. The case underscores the critical importance of following postoperative care instructions to the letter, especially for vulnerable patients.
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.”
