Complaint Investigation Report

Allegation: Staff did not provide adequate supervision which resulted in resident’s death. It is alleged that on December 21, 2024, at approximately 1:50 AM, resident (R1) began experiencing shortness of breath and having trouble ambulating. The complaint alleges night shift staff allowed moderate intellectually disabled resident (R1) to eat unsupervised and did not render aid to the resident in a timely manner, or try to do First Aid/CPR when the resident was choking. The investigation revealed that night shift staff gave the resident water because the resident was coughing but it did not help. Then staff attempted to locate R1's breathing treatment machine but they could not find it. Later staff attempted to take R1 to the bathroom, but the resident was bumping into the wall. Finally, night shift staff called 911 emergency at 3:50 AM.

Based on record review, the resident had a known behavior of wanting to go in the kitchen to get snacks, and staff often had to redirect resident (R1). Staff were aware that the resident needed to be supervised while eating because the resident was at high risk of choking. Based off the information gathered through medical records, Regional Center documents, and interviews with facility staff the findings indicate that either PM or night shift staff did not provide adequate supervision leading resident (R1) to choke on food bolus.

Records revealed the resident had documented dysphagia and required a modified chopped diet due to choking hazard. Staff on duty during the night shift denies the resident accessed the food during their shift and said the resident never woke up and walked to the kitchen prior to the coughing episode. Staff did not follow or implement the measures outlined in the resident’s Individual Program Plan (IPP), and the facility’s Needs and Services Plan. Furthermore, on December 1, 2024, R1 was hospitalized with Pneumonia and Acute Hypoxic Respiratory Failure for Pneumonia and Acute Hypoxic Respiratory Failure (AHRF). Record review revealed no changes to R1's care plan were implemented after their Dec. 1, 2024 hospitalization. The alleged choking incident occurred on December 21, 2024. On December 22, 2024, the resident was hospitalized in critical condition and comatose. On December 25, 2024, the resident was palliatively extubated and died at 1:48 AM. Based on the information, there is sufficient evidence to determine the staff’s failure to provide appropriate care and supervision contributed to resident choking and death.

The issuance of a civil penalty is being considered based on Health & Safety Code HSC § 1548(f)(1)(A), if the department determines the serious bodily injury was due to neglect. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Pursuant to Title 22, California Code of Regulations, deficiencies are cited. Refer to LIC 9099D.

Exit interview was conducted with Program Manager Stephanie Smith. A copy of the report and appeal rights were provided.