Complaint Investigation Report

A review of an Unusual Incident/Injury Report dated 10/19/2023 documented that R1 had a history of choking incidents. On 05/15/2023, R1’s diet was changed from regular to puree. On 08/27/2023, R1 was hospitalized following a choking incident, and on 09/05/2023, their diet was changed from puree to mechanical soft. On 09/26/2023, R1 experienced another choking incident and was assessed by paramedics but was not transported to the hospital. R1’s physician was notified and ordered a barium swallow test with the earliest availability being on 11/30/2023. On 10/18/2023, R1 choked while eating dinner but was able to cough up the food lodged in their throat. Emergency services were activated, and R1 was transported to the hospital for observation. R1 was discharged back to the facility on 10/19/2023 with a diagnosis of esophageal foreign body. Following the hospitalization, facility staff requested that R1’s physician change R1’s diet back to puree. R1’s physician was interviewed and reported that R1 was capable of eating independently and had been prescribed a soft diet.

A review of a law enforcement incident report noted that S1 reported that at approximately 3:00 p.m. R1 was in the dining room and observed eating and interacting with staff. R1’s caregiver, Staff 2 (S2), later transported R1 to their room. Once back at the room, S2 noticed R1 unresponsive and immediately informed S1. Emergency services was contacted via 9-1-1.

Interviews with facility staff were conducted and the following was reported. S1 reported that on 10/27/2023, R1 appeared to be at baseline. Later that day, S2 informed S1 that R1 was unresponsive. S1 responded to R1’s bedroom and observed R1 slumped over with their dentures slightly displaced. S1 denied serving R1 solid food and reported that their duties primarily involved medication management and documentation. S1 further reported that they did not observe any food particles around R1’s mouth.

A review of a law enforcement incident report noted S2 stated to law enforcement that S2 gave R1 a snack at 3:00 p.m. At around 3:20 p.m., S2 observed R1 slumped in their wheelchair and appeared to be sleeping. S2 moved R1 to into their bedroom and asked if they (meaning R1) needed assistance lying on the bed. It was at this time, that S2 observed R1 unresponsive and immediately called S1 for help.