Incident investigation·August 23, 2022

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced case management visit today. The purpose of this visit is conclude the investigation regarding the incident occurred on 03/21/2022. On 03/22/2022, the Department received an unusual incident report (IR) regarding Resident #1 (R1). On 03/21/2022 at approximately 2:24 p.m., staff were alerted to an incident where R1 was found choking in the dining room. Staff performed the Heimlich maneuver and simultaneously, a call to the local fire department and emergency services was placed. At 2:29 p.m. food obstructing R1’s airways appeared to be dislodged. Thereafter, R1 began breathing and the color returned to R1’s face. R1 was then seated in a dining room chair and suddenly became combative. 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 and per their protocol, fire department performed CPR for the next forty (40) minutes. At 3:11 p.m., R1 was pronounced deceased. Cause of death per the death certificate was asphyxia. During the initial visit on 3/25/2022, the LPA reviewed R1's file, obtained pertinent documents and interviewed staff at 9:29 a.m. and 9:52 a.m. On 3/28/2022, additional staff interviews were conducted at 9:45 a.m., 9:55 a.m., and 10:04 a.m. A police report was requested and obtained 3/30/2022. Based on the sheriff’s report, they did not obtain additional information which would suggest that the facility could have prevented the incident from occurring. 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. Upon observation of R1 choking, the staff acted promptly and efficiently, and contacted emergency services immediately. Records review and interviews did not indicate that additional oversight was required for R1. Therefore, based on this review, no further follow up is required at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.