Complaint Investigation Report

supervision to ensure their safety. R1’s mental health antecedents noted that they displayed inappropriate interaction, poor eye contact, compulsive behavior, impulsively, repetitive movements, self-harm, or persistent repetition of words or actions.

Outside Source 1 (OS1) revealed that R1 does not require one-on-one- care; however, both OS1 and the Individual Program Plan (IPP) corroborate that R1 required constant supervision at home and in the community. R1 has a history of choking on their own food and needs to be supervised during mealtime or snacks. It was also noted on R1’s IPP that staff should ensure that they cut R1’s food into small pieces and monitor them while they are eating, as R1 will overstuff their mouth. R1 should be reminded to eat slowly to prevent further choking.

On the night of 07/10/2025, around midnight, R1 was sitting at the kitchen table using their tablet while Staff 1 (S1) and Staff 2 (S2) were on shift. S2 left the area to use the restroom, leaving R1 under the sole supervision of S1. While S2 was away, S1 chose to leave the area and go into R1’s bedroom to find a tablet charger. S1 was aware that S2 was in the restroom at the time, meaning R1 was left completely unattended in the kitchen with direct access to the refrigerator. When S1 returned to the kitchen, S1 discovered R1 eating a hamburger bun. S1 attempted to get R1 to spit out the hamburger bun while trying to remove the bread from their mouth manually, but S1 was unsuccessful. S2 exited the restroom to find R1 still clutching a piece of the bun and struggling to breathe. Both staff members were unable to successfully perform the Heimlich maneuver, and R1 eventually turned purple and collapsed. S2 then called 911 for emergency assistance.

The Hospital medical records revealed that R1’s diagnosis listed Cardiac Arrest (Primary), Acute Respiratory Failure, unspecified whether with hypoxia or hypercapnia, Acute Kidney Injury (AKI), Hyperglycemia, and Aspiration Pneumonia. Statements from Staff 3 (S3), S2, S1, and Staff 4 (S4) confirmed that all staff members were fully aware of R1’s strict dietary restrictions. Specifically, it was well known that R1 was prohibited from consuming solid foods due to a severe choking risk.