Facility Evaluation Report

On 5/30/2023, Licensing Program Analysts Maja Jensen and Jennifer Fain arrived unannounced to deliver findings related to an investigation that was conducted by the Department stemming from an incident report received related to a client death. LPA's Jensen and Fain met with Licensee and explained the purpose of today's visit.

This investigation was conducted as a result a client death on 1/16/23. During the course of this investigation, the Department conducted interviews with staff, clients and a client family member. The Department also reviewed records including but not limited to facility records, medical records, and a coroner’s report.

It was determined that on 1/16/2023 Staff 1 (S1) passed out the breakfast plates for the residents. Resident 1 (R1) was eating his food “fast” with his hands. R1 started coughing while continuing to eat. S1 asked if R1 was okay and R1 nodded his head. Approximately two minutes later, R1’s coughing worsened and his face was turning blue. S1 called 911 and started chest compressions. S1 was able to remove some chewed up food from R1’s throat before paramedics arrived, but R1 was still unconscious. R1’s medical records documented R1 was cyanotic, pulseless, and not breathing when paramedics arrived. Paramedic crews used forceps to remove a “large amount of food” in multiple pieces, approximately "half a hot dog". Paramedics were unable to intubate due to the amount of hot dogs and waffles obstructing his airway. R1 was transported to a medical center. Emergency room doctors were successful to intubate on the fifth try. An attending physician wrote “intubation was complicated due to significant amount of food particles” which were removed using suction and Magill forceps. R1’s responsible party (RP) wished to proceed with comfort care only and R1 was extubated. R1 passed away on 1/16/2023, at 1720 hours.