Complaint Investigation Report

Allegation: Staff did not report incident to appropriate parties

It is being reported that staff did not report an incident in which a client needed the heimlich maneuver performed on them. During file review, LPA observed the physician’s report stating that resident is able to feed themselves, but the weekly PRN Comprehensive Nursing Assessment stated that resident’s diet is mechanical soft and needs verbal prompts to slow down between bites. Resident was eating an item that is determined not to be mechanical soft which resulted on resident choking on an item and the Heimlich maneuver being performed. During file review and interviews LPA learned that an incident report was not filed and incident not being reported to CCLD. On 2/22/24, LPA conducted interviews with both staff and residents. LPA interviewed staff, staff 1 – staff 7 (S-1 – S-7). LPA asked if staff, “Are all incidents reported to the appropriate parties?” Of those interviewed 6 out of 7 stated yes. S-7 was not available for interview. LPA interviewed residents 1 – resident 2 (R-1 – R-2). LPA asked residents, has there been an incident with you that happened that needed to be reported to management. Of those interviewed, 1 out of 2 answered, no. According to the information gathered and the acknowledgment declaration from staff, there is sufficient evidence to support the allegation mentioned above. Based on information gathered, the department did find sufficient evidence to support allegations "Staff did not report incident to appropriate parties.” Therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.