Incident investigation·October 10, 2024

On 10/10/2024, LPA Johnson arrived unannounced to complete an incident report case management follow-up visit. The visit is to deliver findings from an investigation the department conducted to determine if there was any negligence Based on R1's care records, she did not require a special diet. R1, at times would eat quickly so staff cut up certain food for her, like meat, to ensure she didn’t choke. On 8-10-2024, around 1100 hours, R1 ate her lunch, got up from the table, walked to the kitchen area and staff noticed her face turning red. Staff intervened, started the Heimlich and CPR after she collapsed. 911 was called. Paramedics treated R1, but ultimately, they were unable to save her, and she was pronounced dead on scene. The facility had no requirements to cut up R1's food but did it anyway to be safe. R1 never had any sort of food incidents in the past. No further action is required. The facility provided R1 with the required duty of care.