- Date
- 3/6/2023
- Report number
- 00250649-AP-206454
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is care planned for doctor-ordered mechanical soft diet with thin liquids. AV has a history of choking requiring the Heimlich maneuver, after eating foods not on h/h Mechanical soft diet. AV continues to order pizza delivery, shop and purchase h/h own foods including salami. On or about March 06, 2023, AV came out of h/h room choking requiring the Heimlich maneuver. AV became unconscious, without a pulse, chest compressions were started, and AV was transported to the hospital. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing non-compliance to which is a violation of Oregon Administrative Rules.