Complaint Investigation Report

The investigation revealed the following:

Regarding the allegation: "Resident had a choking incident due to staff neglect". It has been alleged that resident choked on a piece of broccoli that was fed to them not according to the prescribed diet.

On 07/17/23 LPA interviewed four (4) staff (S1-S4). Two (2) out of four (4) staff supported the allegation. On 07/18/23 LPA reviewed hospital documents which verify that R1 was struggling to breathe and that broccoli was removed, via forceps, five (5) minutes prior to arrival which resulted in hypoxia and an altered mental status. On 09/26/23 LPA interviewed four (4) additional staff (S5-S8). Out of the interviews conducted on 09/26/23, two (2) out of four (4) interviewees supported the allegation. On 10/25/23 LPA conducted an interview with W1 from LBMH who agrees that R1 aspirated on a diet sized too large. Therefore, five (5) out of nine (9) interviewees have supported the allegation. Interviews indicate that resident was being fed while lying in bed.

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated . California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

An exit interview was conducted with Maria Christina, Administrator, a copy of the appeal rights and this report have been provided.