Complaint Investigation Report

On 2/16/22, a credible witness states, “I believe new staff are not adequately trained.”

On 5/20/23, LPA reviewed training records. Records from March 2021 through February 2022 indicate that staff received training on food preparation on 6/3/2021 and 2/10/2022. LPA compared the facility’s current list of personnel and the food preparation trainings conducted on 6/3/21 and 2/10/22. In the 6/3/21 training, 7 out of 34 staff employed as of 2/14/22 received the meal preparation training. In the 2/10/22 training, 6 out of 34 staff received this training.

Based on the evidence obtained, the allegation, “Facility staff are not adequately trained,” is deemed Substantiated at this time. Deficiency cited.

On the allegation, “Staff fed resident an inappropriate food item,” the complainant’s concern was that staff fed Client #1 (C1), who requires a pureed diet, a full piece of fried chicken with bones in it, and the client choked on it and threw it up. To investigate, LPA interviewed staff and reviewed records.

On 2/15/22, LPA interviewed staff. Staff say that on one occasion, they fed C1 chicken and mashed potatoes. They say they prepared boneless fried chicken and that the breading was crispy on the edges. Staff say when C1 ate the mashed potatoes, there was no problem, however, when C1 ate the chicken, C1 choked on the chicken and vomited some of it up. Staff describes the pieces of chicken as “3-4 pieces, 4-5 inches long.” Staff also say that they served eggs and hashbrowns to C1, and C1 was “eating, not swallowing, then pushed away the food, began coughing, and threw up the food.” Staff say that C1 “shoves large portions of food in their mouth unless staff tell them otherwise.” Staff says they give C1 a full plate of food and chop the food into small bites” and that staff coach C1 on eating properly. Staff says that when they were first hired, they received training on preparing mechanical soft food, but since then says they have not attended any other trainings recently.

On 12/21/22, LPA reviewed the face sheet for C1 which indicates C1 has a “Regular pureed” diet. Staff say they use the face sheet as a resource to know how to care for clients.