Complaint Investigation Report

Regarding allegation: Questionable Death. It was alleged that the client was not aided with proper lifesaving actions and passed away as a result.

C1 passed away on 2/16/25. Interviews were conducted with Administrator, staff and Regional Center staff. Records were also reviewed including paramedic’s / EMS report and coroner's report / Death certificate. Interviewed Administrator and staff stated, on 02/16/25 after C1 ate their breakfast in the morning, after a while C1 went to the kitchen and brought out bread and peanut butter. Staff assisted C1 and C1 was eating their sandwich at about 11:52am. Per C1’s IPP C1 chooses what they would like to eat for breakfast and lunch and staff will assist with meal preparations (Per C1’s IPP and Health Report C1 has been eating a lot and does not know when to stop). Interviewed Administrator stated whenever C1 was eating, staff were always with her by the table to remind her to slow down, finish what is in her mouth before taking another bite. Per C1’s file review, C1 did not have a history of choking but was known to be a rapid eater and documentation states C1 eats independently and feeds herself. While eating the sandwich C1 was redirected several times to slow down when eating. S1 and S2 who were sitting around the table with C1 noticed C1 was choking. S1 quickly gave C1 abdominal thrusts while S2 called 911. C1 s pit a little out and still wanted to pick the remaining sandwich, but staff told her to leave it. Paramedics came in at about 11:57am. S1 was still doing the abdominal thrust when the paramedics came, S1 was told to step aside, and they took over. They were able to suction some food out. After noticing that C1's oxygen saturation is getting low, they gave oxygen to C1 and took C1 to the hospital at about 12:20pm. S2 was with C1 in the ambulance on the way to the hospital. Medical / paramedics reports indicate "C1 was choking on a PB&J sandwich and became cyanotic. EMS was called and were able to dislodge some of the food. After the oxygen level was getting low, EMS took C1 in the ambulance to the hospital". S2 stated that medical staff was performing CPR on C1 in the ambulance and in the hospital. Administrator who had already arrived at the hospital was informed that C1 had passed away.