Complaint Investigation Report

Allegation: Staff did not ensure resident's dietary needs were met resulting in the resident choking. The complaint alleges that on 6/15/2025 during breakfast meal time Memory Care resident (R1) was served the wrong diet plate and choked on a piece of sausage. According to information obtained, at the time of the incident R1 was on mechanical soft diet, but was given a regular diet plate. A total of five (5) residents were interviewed. None of the residents reported issues with the facility not following their physician order diet. Based on staff interviews, a staff person observed the resident choking and gasping for air. Staff immediately performed Heimlich maneuver and inserted two fingers when the food item was not being expelled. After the piece of sausage was expelled the resident displayed shortness of breath, which resulted in need of emergency services. All staff interviewed confirmed the resident choked because they were served the wrong food diet plate. Staff interviews revealed the staff person who served R1 their plate was unaware the resident required a special diet. Record review confirmed R1 required a mechanical soft diet at the time of the incident. There is sufficient evidence to corroborate the allegaiton.

Allegation: Staff did not provide resident's advance directive and/or request to emergency personnel.

It is alleged that facility staff did not provide emergency personnel resident (R1's) "Do Not Resuscitate [DNR]" form and other necessary records. A total of five (5) residents were interviewed. None reported issues with POLST or DNR documents. Staff interviews revealed that on June 15, 2025, when 911 emergency services personnel arrived at the facility and determined the resident required transport to the hospital, staff were not able to print any of the residents documents that are normally provided to emergency personnel. Staff stated that the med-tech room computer broke the day before, and the computer used the day of the incident had printing issues. Therefore, emergency personnel were not provided necessary documents i.e., Face Sheet, medication list, POLST/DNR, and medical assessment. Staff stated they asked paramedics to take a picture of the records. It is unknown which documents the paramedics took pictures of. Advance directive and/or request regarding resuscitative measures forms shall be presented to the responding emergency medical personnel. Therefore, there is sufficient evidence to corroborate the allegation.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED .

An exit interview was conducted with Human Resources Director Nadia Batista. A copy of the report and appeal rights were issued.