Incident investigation·March 25, 2022

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced case management visit today to obtain additional information surrounding an incident that occurred on 03/21/2022. The LPA met with RN Brianne Fowler and Executive Director Dmitry Estrin and explained the reason for the visit. On 03/22/2022, the Department received an unusual incident report regarding Resident #1 (R1). It was reported that on 03/21/2022 at approximately 2:24 p.m., staff were notified that R1 was choking in the Avalon dining room. Upon arrival, R1 was observed gasping for air and the color had drained from R1's face. Staff performed the Heimlich maneuver and a call to the local fire department and emergency services was placed. At approximately 2:29 p.m. the object obstructing R1’s airways appeared to be dislodged. Thereafter, R1 began breathing and the color returned to R1’s face. R1 was seated in a chair and became combative. R1 began kicking staff and tried to push them away. The local fire department arrived on the scene at approximately 2:32 p.m. As the fire department approached the dining room, R1 became unresponsive. The local fire department immediately began CPR. At 3:11 p.m., R1 was pronounced deceased. During today's visit, the LPA reviewed R1's file, obtained pertinent documents and interviewed staff. Per the records review, R1 did not require special dietary accommodations, did not required a pureed and/or chopped diet, and was independent of facility services. Further investigation is required at this time. Exit interview conducted. A copy of the report was issued.