complaint·December 1, 2021

Orange County EMS report obtained notes the incident as taking place at approximately 5:39 PM. Paramedics arrived on the scene around 5:43 PM and were unsuccessful in reviving resident. R1 was pronounced deceased at the scene at 6:04 PM by the responding paramedics. R1’s medical examiner’s report dated 07/14/2021 lists R1’s cause of death as asphyxia due to upper airway obstruction, food bolus aspiration. A police report obtained from local police reveal responding officers were called at approximately 6:09 PM to investigate the deceased resident. The responding officer did not observe any signs of struggle or anything unusual. No signs of physical injuries were noted. Witnesses interviewed reported the meal provided that day was chicken cut up in small pieces and a salad. Both caregivers present at time of incident reported they responded immediately to the resident’s alert. During an initial visit to the facility, LPA Lyman observed the facility call system. All residents have a motion detector in their room as well as a pendant. When a resident moves or pushes the pendant, the centralized system goes off in the kitchen. The alert goes off until the staff manually reset the system. There are no print outs or a time stamp to verify what time the system went off or when staff responded during the incident. R1’s responsible party reported R1 had a near choking incident with a few days prior during an lunch outing together. R1’s Responsible party reported they had notified staff about the incident upon returning R1 to the facility that same day. Both administrators and two of three staff interviewed deny any knowledge of a prior choking incident. The remaining staff member reported vaguely recalling a conversation with the responsible party regarding R1’s near choking incident while out to lunch with the R1’s responsible party and stated they instructed R1’s responsible party to discuss it with the facility Administrator. All staff indicate no knowledge of a change in supervision requirements or dietary restrictions. All staff interviewed denied ever observing R1 have issues while eating. R1’s physician report dated 04/02/2021 and Appraisal Needs and Services dated 04/20/2021 list R1 as able to feed themself. The appraisal states R1 needs medium to maximum assist in all ADL’s related to the lower body only. Hospice records reviewed did not notate a need to supervise R1 while eating. Based on multiple interviews conducted and documents reviewed, there is not enough evidence or corroborating information to support the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator and a copy of this report was left at the facility. Exit interview conducted and a copy of this report was left at the facility. Hospice records obtained and reviewed do not indicate any dietary restrictions for R1. R1’s physician report dated 04/02/2021 list R1 as able to feed themself. All staff interviewed reported R1 had no issues observed while eating prior to the 7/10/2021 choking of R1. Therefore, based on the records reviewed and interviews conducted, the allegation is deemed UNFOUNDED, meaning the allegations is false, could not have happened and/or is without a reasonable basis.