Complaint Investigation Report

Although Coroner’s Reports indicated asphyxia due to aspiration of food and probable asphyxia due to obstruction of larynx by food bolus as cause of death for R1 and R2 respectively, 9 out of 10 residents indicated staff do not rush them when eating. LPA was unable to obtain information from one of the residents

All 3 staff interviewed denied rushing the residents when eating. All 3 staff stated R1 was eating when R1 choked, Staff performed Heimlich maneuver and called 9-1-1 immediately. R2 was done eating when R2 fell. R2 didn’t show signs of choking when the incident happened. Staff acted accordingly by performing CPR and called 9-1-1. R1 and R2 were pronounced dead on the scene. FM2 was aware of R2’s incident but was not able to provide information. FM22 stated he has visited R2 at the facility, and didn’t observe any signs of abuse or neglect, and felt the staff are very caring and kind.

Information obtained from staff that R1 and R2 can feed selves were consistent with the Physician’s Reports. FM22 also stated R2 can eat on his own.

Based on LPA’s interviews, records and documents review, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted, and copy of this report provided.