Incident investigation·February 21, 2023

LPA Parks arrived on Tuesday February 21, 2023 to conduct a case management visit. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. This is a follow up visit for an incident that occurred on 2/14/2023. As R1 was eating dinner, he began to choke. S1 performed the Heimlich maneuver. After the abdominal thrusts were unsuccessful, S2 began to perform CPR per the 911 operator's instructions. Approximately two minutes later, paramedics arrived and took over. R1 was transported to the hospital. R1 passed away on 2/15/2023. LPA interviewed S2 who was present during the incident. Additionally, R1’s spouse (R2) was interviewed. LPA obtained R1's physicians report, care plan, and copies of staff CPR/First aid certificates. LPA also obtained contact information for one staff and one visitor who assisted during the incident. No deficiencies were cited. Exit interview conducted.