Complaint Investigation Report

The local Regional Center reported that there were no Special Incident Reports related to R1 choking. Interviews for the staff that worked on 10/12/2022 during the PM Shift, did acknowledge barbecue ribs were served for dinner and that R1 did enjoy eating ribs. All staff interviewed reported no unusual behaviors that evening. R1 would get up in the middle of the night, but usually only to use the bathroom or get a glass of water from the kitchen. S3 stated at nighttime “R1 wasn’t the type to take food in general and look for something to take.” S1 shared that S1 did not sleep during the shift and the only time R1 left the room that evening was when S1 got R1s attention when S1 was in the kitchen. S1 did not see R1 obtain food items from the refrigerator.

R1 passed away at the hospital. R1 was described as a well-developed and well-nourished individual, and R1s upper and lower teeth were intact. There was no evidence of external injury, and R1s cause of death was determined to be an accident.

Based on interviews conducted and a review of pertinent records, the facility made efforts to address R1s productive cough with eating and drinking as staff took R1 for a follow-up with the doctor (DR) on 09/06/2022, and the subsequent Swallow Evaluation was performed on 10/03/2022. There were no instructions for facility staff for R1 to have nothing by mouth as DR was not made aware of the Swallow Evaluation results until 10/13/2022.

For the allegation of Staff made false statements regarding death, RP was told at different times by staff (names unknown) that R1 went to the kitchen for water, R1 looked strange, and collapsed. Another version is that R1 went to restroom and collapsed. A different version was that R1 was standing against the wall and staff began CPR on R1 while standing, and the last version was that R1 came to and walked outside with paramedics to the ambulance.

F1 did acknowledge the information S4 was providing, was relayed to S4 by the facility staff working on 10/13/2022. The last version is being told by S4 that R1 choked on water and died.

In the departments interview with S4, it was stated S4 has spoken to F1 in the past, but not about R1s specific cause of death. S4 contacted F1 on the morning of R1s death to let F1 know about the incident. S4 acknowledged R1 got up to get water and staff followed R1 to the bathroom as that was what was reported to S4 by staff.