- Date
- 8/19/2020
- Report number
- 00098750-AP-074879
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) was an aspiration risk, had a known history of choking, and overfilling his/her mouth with food. The aspiration precautions/recommendations in place, dated August 6, 2020, called for supervision one on one, cueing to slow down, small bites/sips, eat slowly, and if AV were to begin choking or coughing, cue to stop eating and resume only after airway cleared. Staff were to provide verbal redirection to stop impulsivity, and meals be served in 1/3 portions at a time. On or about August 19, 2020, AV was served his/her place of breakfast and was observed "stuffing" bits of waffle into his/her mouth. Staff were busy delivering food trays to all of the other residents in the dining room. Shortly after 8 AM, AV suddenly stood up from the table and began ambulating towards his/her room. A staff member followed and soon realized AV was choking. Staff attempted to clear AV's airway and called emergency services. EMT's arrived and were able to clear AV's airway and intubated AV for a short time. AV was pronounced dead at 8:42am. The facility failed to follow AV's swallow precautions/recommendation on the morning on August 19, 2020. AV was not directly supervised by a staff member at the table, nor was AV provided one on one cueing to slow down and/or stop from overfilling his/her mouth with food, which is violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP20-01518 $15000.00 fine assessed