complaint·September 13, 2023

** report amended on 9/27/23** Records and statements found that R1 was admitted to this facility on 2/21/23. R1 had a physician’s report (LIC 602) at admission, dated 9/16/22. The 9/16/22 LIC 602 stated that R1 had Parkinson’s disease, cognitive issues, no special diet and hand written notes on the LIC 602 that R1 needs help cutting food. On ** 2/21/23, the facility received a physician’s order for R1’s food to be chopped in general and an order of a mechanical soft diet. (The University of Toledo describes a mechanical soft diet as- Level 2: consists of foods that are moist, soft-texture, and easily swallowed. Meats are ground or finely cut to equal size no bigger than ¼ inch. Or Level 3: includes food that is nearly normal excluding very hard, sticky, or crunchy foods. Foods should not be overly dry and should still be moist and bite sized. https://www.utoledo.edu/depts/csa/caringweb/softdiet.html ). The licensee provided records to the investigator that on 3/29/23 training was provided to food service staff regarding Textured Modified Diets and Thickened Liquids that identify a mechanical soft diet for meats to be served ground and moistened with gravy or sauce. The Resident Functional Evaluation provided to the Department for R1, dated 2/21/23 notes R1 requires reminders for eating rather than alternative designation of Needs assistance in cutting food or supervision during meals. A second Resident Functional Evaluation form was submitted, however, it did not identify a resident or evaluator, but identifies resident preferred name of an abbreviation of R1’s name. In this form it is noted: Special diet- Chopped, Types of assistance- cutting of meat, and Eating- Has eating or swallowing difficulties requiring complete assistance and supervision during meals. The resident assessments were reviewed and approved, on a RCFE Assisted Living Prospective Resident Approval Review form, by Assistant Executive Director, Ryan Nakao, Residential Living Advisor, Shanti Willis and Resident Care Coordinator, Chantel Krahn. Staff interviews and records indicated that on 3/11/23, Kitchen Supervisors, S3 and S4, were managing food service. The resident’s food was to be prepared and packaged for R1 to receive in their room. S3 and S4 failed to adhere to the Dietary/ Nursing Communication which was posted for R1. The Aforementioned communication designated R1’s diet of Solids- Mechanical Soft Chopped & Bite Sized. Instead, on 3/11/23, Kitchen Supervisors prepared R1’s meal to include three (3) pieces of meat that were not chopped nor bite sized. The food was placed in a Styrofoam container with a lid and placed in a plastic bag. S3 and S4 were subsequently terminated on 3/24/23 after the licensee completed their internal investigation. For both S3 and S4, the termination letters noted: “…you did not and have not consistently provided supervision necessary to ensure that residents who required special diets actually received them. As a result, multiple residents have received food that was not appropriately prepared for them in accordance with their dietary orders, placing them at risk.” Interviews and records review found that on 3/11/23, at approximately 5:25 PM, caregiver S1 delivered the packaged meal to R1’s room. In a statement, S1 stated that she was unaware of R1’s dietary restrictions and had not been instructed to examine the contents of R1’s meal prior to delivering the meal to R1’s room. S1 acknowledged during interview that S1 left the food unattended in order to empty the trash. While S1 was not present, R1 attempted to eat the food which was delivered, choked and was found by a medication technician, S2, a short time later. The Department’s review of meal preparations procedures in place on 3/11/23 found that S3 and S4 were responsible to ensure that residents’ food be reviewed for quality and dietary accuracy before it is released for delivery to residents. The licensee’s and the Department’s investigations found that S3 and S4 failed to prepare R1’s diet properly and failed to review R1’s food before being packaged for delivery. Procedures did not contain provisions for caregiver review of food and diet when food was to be delivered by staff, as in the case of R1 who was required to remain in their room under quarantine . Therefore, S1 was unaware of R1’s diet restrictions and the contents of the meal when S1 left R1 unattended and R1 was able to access the meal. This procedural oversight resulted in R1 lacking proper supervision and assistance with their meal, consuming improperly prepared food, choking, hospitalization and eventual death. In addition to the failure on the parts of S3 and S4 to properly prepare the food for R1 on 3/11/23, the investigation also found: S3’s and S4’s incidents of, as their terminations letters state- “ multiple residents have received food that was not appropriately prepared”- had not been addressed in supervisor action prior to the incident on 3/11/23; that the procedures in place did not address individual meal verification when delivered to resident rooms; and that S1 was not provided appropriate training regarding R1’s dietary needs and assistance with cutting food. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident death while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted. Report reviewed with Executive Director . Copy of this report and appeal rights provided.