Incident investigation·December 21, 2022

On 12/21/2022, Licensing Program Analyst (LPA) conducted a case management visit to follow-up on a case management visit that was conducted on 8/11/2022 regarding an incident that was reported to CCL by the facility. On 8/4/2022, facility reported resident #1 (R1) was eating dinner and staff noted R1 ceased breathing, became pale, and was holding own chest and neck. Staff performed Heimlich Maneuver, called 911 and R1 was pronounced deceased by the paramedics. On 8/11/2022, LPA conducted a case management regarding the incident and collected documents. Based on R1 doctor's documentation, the cause of death is Aspiration, Chronic Dysphagia, Lewy Body Dementia. Based on Medical Examiner's report, Manner of Death - Accident and Method of Death- Aspiration Food. LPA interviewed the assistant administrator who stated that R1 did not required a special diet and R1 did not need assistance with feeding but staff provided supervision during R1's meal times. In addition, the assistant administrator stated that when staff noted R1's condition on 8/4/2022, staff took immediate actions. Based on the documents provided, LPA observed R1 was not on a special diet and R1 was able to feed self during meals. Based on staff documentation, when staff #1(S1) observed R1 was having difficulty breathing, turning pale and hold own chest and neck, S1 called for Staff #2 (S2) who is a licensed professional for assistance and when S2 arrived, S2 took over the Heimlich Maneuver from S1 while S1 proceed to call 911. While waiting for the paramedics, S2 administered oxygen to R1. Based on records review and interviews, there is no lack of supervision and neglect observed, No deficiency cited today. This report is reviewed and discussed with administrator. A copy is provided.