Complaint Investigation Report

LPA Marrufo obtained a copy of R1’s Appraisal/Needs and Services Plan (A/NS), dated 08/09/2024. The “Background Information” section of the A/NS states “with assistance with [his/her] ADLs (Activities of Daily Living) and Transfers.” The Functioning Skills section states “[R1] is independent.” The A/NS does not include details of R1’s needs related to ADLs, transfers, special diet, and feeding. R1’s A/NS Plan was signed by the facility Administrator/Licensee on 08/09/2024. The signature fields for the client/resident’s authorized representative are blank.

LPA Marrufo obtained copies of R1’s Progress Notes written by R1’s Speech Therapist. The Progress Note from 08/16/2024 states “Avoid bread items, except for very soft and moist textures like banana bread cut on to bite size.” The Progress Note from 08/28/2024 states “Pls (sic) provide feeding assistance & offer water every hour until pt can feed [him/her]self independently.” The Progress Note from 09/06/2024 states, “Downgrade diet level to soft + bite sized texture as pt eats alone sometimes & pt may self-feed large bites w/o supervision. ** No Bread.” The Progress Note from 09/16/24 states, “Pls make sure to avoid bread items – pancakes, toast, etc.” The Progress Note from 10/04/2024 at 11:10 states, “Pls make sure pt receiving safe & bite-sized texture only. Pt choked today. It can happen again. Avoid all breads. Pls refer to the soft & bite-sized handout if needed.”

During visit on 10/11/2024, LPA Marrufo interviewed R1. R1 stated to not have a special diet. R1 stated R1 requires food to be soft. R1 stated R1 likes food to be textured but does not require it to be. R1 stated staff always provide R1 with soft and textured food.

R1 stated that R1 has chocked on food while at the facility. R1 stated to have chocked on big chunks of apple pie with a “rustic crust.” R1 stated R1’s speech therapist fed R1 the apple pie. R1 stated the speech therapist is not a staff of the facility. R1 stated the speech therapist feeds R1 to check R1’s swallowing and chewing. R1 stated the apple pie came from the facility kitchen. R1 states to not know why the staff did not cut up the apple pie into smaller pieces.

During interview on 10/11/2024, facility manager M1 stated that R1 had a choking incident on 10/04/2024 at noon during lunch. M1 stated that R1’s meal came from the facility kitchen. M1 stated neither M1 nor the facility staff were told that R1’s Speech Therapist would be feeding R1. M1 stated R1’s order for soft and textured food came from home health and the facility does not have R1’s home health plan. M1 stated R1 is a manual feeder and can feed himself/herself independently. Page 2 of 5.