- Date
- 4/4/2025
- Report number
- 00393716-AP-344382
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a therapeutic diet
- Result
- Substantiated
- Findings
- According to the documentation, the facility failed to follow the therapeutic diet ordered for the Alleged Victim (AV) for their known history of choking on solid food. On or about March 25, 2025, the AV moved into the facility and had orders for a modified diet texture. The care plan dated March 26, 2025, reflected these orders and the kitchen was notified of the dietary orders for the AV. The kitchen has a board where they write all modified diet textures on it and AV was on that board. On or about April 04, 2025, the AV received food that did not follow the diet texture order. The AV choked on the food which required staff to perform the Heimlich maneuver in order to dislodge the food. The failure to follow diet texture orders caused the AV to choke, requiring the Heimlich maneuver to dislodge the food, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP25-00165 $338.00 fine assessed