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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1068475-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler Suspected Maltreatment Reported: It was reported a vulnerable adult (VA) passed away after a staff person (SP) prepared his/her food incorrectly and the VA choked on a sandwich. Additionally, there were concerns 9-1-1 was not contacted immediately upon the VA choking. Date of Incident(s): June 26, 2022 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 28, 2022; from documentation at the facility, a review of the video of the incident; and through eight interviews conducted with the VA’s guardian (G), facility staff persons (P1-P2), facility supervisors (P3-P5), the VA’s case manager (CM), and the SP. Facility documentation showed the VA could “flash a great smile,” and enjoyed engaging in sensory activities, listening to music, dancing, and spending time outside. The VA liked going on walks, swimming, and working with tools on small machines like vacuums and leaf blowers. The VA’s daily routine made it “easier” for the VA’s “strengths and abilities to shine.” The VA used gestures and/or guided people to communicate his/her wants/needs. The VA required 1:1 supervision 24 hours a day, and it was important for staff persons to know the VA’s communication style and how to understand his/her needs. The VA could become over stimulated and engage in negative behaviors, which included his/her mind racing, getting “amped up,” and had both “happy” and “mad” tics. The VA was diagnosed with developmental disabilities, autism, mood disorder, and dysphagia. The VA used a Provale Cup to slow his/her drinking of liquids. While eating, the VA needed assistance and constant supervision. The VA’s food should be bite sized and/or “cut up,” but there was no specific information related to the maximum size of each bite, nor a description of a measurement and/or other sized comparison items for each bite. Additionally, the VA should be monitored for portion control and “overstuffing” his/her mouth with food. The VA would attempt to “eat fast” and not “chew” his/her food well and/or “swallow it whole.” The VA “would not seek any assistance in an emergency” and would not be able to “recognize an emergency.” The VA did not have the judgment and physical ability to cope, make appropriate decisions and act in a changing environment or a potentially harmful situation. Additionally, if the VA was “overwhelmed and overstimulated” s/he could get “stuck and sit down and refuse to move.” This could be dangerous for both the VA and the staff in emergency situations. The VA engaged in self-injurious behaviors, as well as physical aggression towards others. Due to the VA’s behaviors and needs his/her room was located in the basement of the facility. On February 11, 2019, the VA had a Speech Therapy Assessment, which included a swallow assessment. It was recommended 1:1 feeding assistance; however, no other restrictions were stated. On August 9, 2019, the VA completed a Video Swallow Study, and orders for liquid intake including the use of the Provale Cup; however, there were no specific details related to the VA’s food/diet intake. An (unnamed and undated) document within the VA’s file showed “rules” were put in place to minimize the risk of choking. The VA’s food should be “small manageable bites” which included “pizza, sandwiches etc.” Staff were required to sit next to the VA while eating and direct the VA to take one bite at a time. The VA should “take sips of water between bites,” as that ensured the VA was “chewing and swallowing” the food entirely before taking the next bite. It was noted that “staff MUST take this very seriously,” as the VA had a “very real risk of choking and aspirating while eating.” The VA’s Coordinated Services and Support Plan Addendum (CSSPA) showed the VA followed a dysphagia diet in which food must be cut up for him/her before eating. Staff persons were trained on choking and finger sweeps during orientation course work of chest compressions and First Aid, which was renewed annually. All of the VA’s liquids were consumed using a special cup (Provale cup) which slowed the VA’s ability to drink liquids and reduced choking. The diet plan was posted in his/her kitchenette area and staff were trained during on-site orientation; and reviewed as necessary. On March 25, 2022, the facility completed a training on the VA’s “snacks & feeding rules.” Multiple staff attended the training including P1-P2, and the SP. On May 27, 2022, P5, the G, and the CM completed a team meeting regarding the VA, and P5 documented the information from the meeting. The meeting notes detailed the VA did not have any specific food restrictions, but required his/her food to be in bite size pieces. Additionally, the G requested the VA be provided “bigger snacks” such as peanut butter and jelly sandwiches. Additional topics were discussed and documented, but did not directly relate to the investigation. The G provided the following information: · The G said s/he was provided “three different scenarios” and different timeframes regarding the incident involving the VA, and was not sure what actually occurred. The G said it seemed like there was information that was either missing or lacked details, however the following information was provided to the G: - The SP made the VA a sandwich and was making a second sandwich when the VA started choking. - The VA put a quarter of the sandwich in his/her mouth prior to choking. - The staff did not call 9-1-1 until the VA had “passed out,” and there was a lapse in time (unknown duration) before 9-1-1 was contacted. - The staff were just standing around when emergency personnel arrived. - The G “heard” the facility had a meeting after the VA passed away, and the meeting was about a non-verbal person choking. The G said the facility told employees to “keep their mouths quiet,” after the incident. · The G also expressed frustration regarding: - The staff should have been trying to help the VA “nonstop” during the incident. - The G was not contacted by the facility about the incident, but rather the medical facility called him/her around 12 p.m., and the medical facility informed the G the VA had not had oxygen for 30-40 minutes. - The G believed 9-1-1 should have been called sooner, and believed the facility may have been short staffed. - The G was not sure if the VA was unsupervised during the incident, but from past observations felt the staff at the facility “rushed” the VA which led to the VA getting frustrated. · After the incident the G spoke with a medical provider and the medical provider said the VA should not have had a peanut butter sandwich, and the VA should have had bite sized food with something to drink on the side. The G added the VA had a previous incident in which s/he choked on a sandwich and was seen at a medical facility. Thereafter, the VA completed a swallow study sometime in 2018 or 2019. · The VA was not supposed to be provided peanut butter sandwiches and the G “stayed away from peanut butter bread,” but later added when s/he gave the VA peanut butter sandwiches, “we” (when the VA was living with the G) would be right next to the VA, and the sandwich was cut into small pieces. Moreover, the VA would be provided a harder food prior to the peanut butter sandwich. · The VA would “grab” or “run away” from persons if s/he was in a crisis. In the previous incident the staff chased the VA and had to dig the food out of the VA’s mouth. The G said the VA would have been panicking from choking, and the VA could have pushed staff away during the incident. · The G felt like the facility lied to him/her dating back to 2014 when the VA moved into the facility. The CM said there was a team meeting and the VA’s eating habits were discussed, but was unsure if the specific details of peanut butter sandwiches were discussed. The CM believed the VA liked peanut butter sandwiches, and the VA had previously eaten peanut butter sandwiches. The incident was captured on a video recording. P5 and P6 reviewed the video with this investigator. The entire video (35 minutes and 28 seconds) was reviewed with the incident occurring between 10:30-10:40 a.m. Because there was no sound to the video, P5-P6 provided information regarding the VA’s behavior and interaction. The following is a description of the incident: - During the first five minutes of the video the VA and the SP were in the kitchen, and they looked at multiple food items in a cabinet and the refrigerator. The VA sat down on the floor multiple times, which was a common behavior according to P5, and the SP remained within a close proximity of the VA (0-5 feet) for the duration of the time. Within that time the SP took milk from the refrigerator and s/he checked the VA’s mouth at the 3:29 minute mark. - 4:28: While the SP was making the VA a packet of oatmeal the VA pointed towards a cabinet, and the SP acknowledged the VA’s communicated gesture. - 4:29-4:42: The VA stood up, and removed peanut butter and bread from the cabinet. - 4:51: The SP took the peanut butter and bread and started to make a sandwich for the VA. The SP took one piece of bread, smeared peanut butter on half of it, and folded the piece of bread in half. - 5:36: The SP held the peanut butter sandwich and provided the VA with a bite of the sandwich while the VA was seated on the floor. Based on the video, the bite was approximately half of the sandwich, and the SP kept the remaining sandwich in his/her hand. The SP took a cell phone out of his/her pocket at the 5:40 minute mark, and used his/her cell phone until s/he provided the VA with a second bite of the sandwich. The SP was positioned next to the VA while s/he used his/her cell phone. (Within the SP’s interview s/he said the phone was used to play music.) - 5:51: The SP remained in control of the sandwich and provided the VA with a second bite, finishing the sandwich. The SP proceeded to put his/her cell phone away at the 5:56 minute mark. - 6:05: The SP started making a second sandwich and made eye contact with the VA multiple times between 6:05 and 6:20, and was within five feet of the VA. - 6:25: The SP grabbed a cup, slightly turned his/her body away from the VA, and started to pour a glass of milk. - 6:33: While sitting on the floor, the VA made a sudden movement with his/her arms around his/her head. - 6:34: The SP turned around and had visual contact of the VA. - 6:37: The VA stood up, pulled the neck of his/her shirt over his/her mouth, and left the kitchen area. The SP, with the cup of milk, followed immediately behind the VA. - 6:45: The VA entered the dining area, and sat on the floor. The SP offered the VA milk, however the VA refused. The VA got up off the floor and left the dining area. The SP attempted to reach for the back of the VA’s shirt at the 6:52 minute mark, prior to the SP and VA going out of the camera view. - 7:02: The VA quickly entered a common area and sat down on the floor. The SP was following directly behind the VA. The VA rolled over on the floor and stood up, the SP attempted to have the VA take a drink, however the VA pushed the SP away, and attempted to run around the SP. The SP blocked the VA initially from exiting the area. However, the VA sat/rolled on the floor and stood back up prior to moving around the SP into the next room. - 7:18: The VA entered a second common area and fell onto a chair (partly out of the camera view). The SP entered the room immediately behind the VA, and attempted to have the VA take a drink. - 7:20: The SP attempted to physically provide the VA with a drink. The SP had ahold of the VA’s shirt and attempted to hold the VA in place against a wall, however the VA pushed away the cup of liquid. - 7:31: The VA was able to maneuver around the SP, pushed the SP away, and attempted to move towards the stairs. The SP cut the VA off and physically guided the VA into a corner of the room. - 7:28: P1 entered the room, and started moving towards the SP and the VA. However, the VA made a quick movement around the SP, and attempted to go towards the stairs. During the VA’s movement the cup of milk the SP was holding was knocked out of his/her hand. - 7:32: The SP attempted to physically hold the VA, however the VA again sat down and rolled out of the SP grasp. - 7:38: The VA stood up from the floor and started going downstairs. The SP motioned towards P1 and communicated (unknown statement as there was no volume) with P1, who ran into a different room (out of the camera view). - 7:45: The VA entered the downstairs dining area and the SP followed behind, and attempted to hold onto the VA’s shirt from behind. The VA again sat down on the floor and the SP attempted to get water from the sink. - 7:53: While seated on the floor the VA scooted into a room outside camera view. The SP, with a cup of water, immediately followed behind into the other room. - 8:01: The VA entered the downstairs common area and stood up, as the SP followed immediately behind. The VA struggled walking, and started to stagger towards a sofa on the far end of the room. The SP was directly behind the VA, and the VA fell slowly to the floor just prior to reaching the sofa. - 8:07: The SP attempted to provide the VA with water and moved the VA away from the sofa. - 8:20: P1 entered the camera view with a cup, and ran over to the VA and SP. P1 attempted to provide the VA with the cup of water, however set the water down to assist the SP in positioning the VA. - 8:35: P1 attempted to provide water to the VA. - 8:37: The VA went limp and the SP was positioned behind him/her and, started to complete the Heimlich maneuver. P3 quickly entered and exited the camera view at 8:50, while the SP continued to perform the Heimlich and P2 observed the VA’s face. - 8:57: The VA attempted to move away from the SP, and rolled out of the SP’s grasp. - 9:03: The VA attempted to sit upright, and the SP held his/her arm, however the VA again went limp and fell backwards. P1 and the SP positioned the VA on his/her back and the SP started chest compressions at the 9:14 minute mark. - 9:20: P1 left the area, and the SP continued chest compressions. - 9:27: The VA moved to his/her right side and the SP stopped chest compressions. The VA turned away from the SP, and the SP assisted the VA into a sitting position. The SP attempted to provide the VA with water, and it appeared the VA drank water, however it was unknown how much, or if any of the water was consumed. - 9:41: The VA went limp and back to the floor. The SP attempted to reposition the VA into a seated position and started to perform abdominal thrusts while seated behind the VA. - 9:59: P2 entered the area while on the phone and quickly left, before reentering the room at the 10:06 minute mark. - 10:09: The SP stopped completing the abdominal thrusts, and took the phone from P2. P1 walked over to the SP and VA, and P1 moved the VA’s head and appeared to look at the VA’s face/mouth. P1 and P2 placed the VA in a supine position on the floor. 10:28: The SP left the area while on the phone. The VA remained in the supine position and P1 started chest compressions, and P2 supported the VA’s head. At the 10:38 minute mark P2 appeared to take the VA’s pulse. - 10:43: P1 stopped chest compressions and observed the VA’s mouth/face. P1 and P2 appear to communicate, however there was no sound and it was unknown what was communicated. - 10:58: P1 and P2 lifted the VA’s shirt to observe the VA’s abdomen. - 11:09: P2 placed his/her head near the VA’s heart. - 11:24: The SP entered the camera view and was on the phone. - 11:50: The SP set the phone (9-1-1) down next to the VA and reengaged in chest compressions, while P1 held the VA’s head. The SP briefly stopped chest compressions at 11:57 minute mark, however P2 was blocking the camera view and it was unclear if the SP attempted to clear anything from the VA’s mouth or completed some other action. - 12:35: P2 left the room and returned at 13:25. P2 observed the VA, the SP, and P1 from the entrance of the room. - 13:45: The SP stopped chest compressions and attempted to clear the VA’s mouth by sweeping his/her finger in the VA’s mouth. It was unknown if any substance was removed. - 13:51: The SP restarted chest compressions with P1 supporting the VA’s head. - 14:16: P2 took over supporting the VA’s head, and the SP completed another finger sweep of the VA’s mouth, before P1 restarted chest compressions. - 14:41: The SP ran out of the camera view and P1 continued chest compressions with P2 supporting the VA’s neck. - 15:38: The SP entered the camera view while on the phone and left again at 15:44. - 16:39: The SP entered the camera view and put a bag on the ground. A Law Enforcement officer (LEO) entered the room at 16:46. A second LEO entered the room at 17:00. - 18:53: LEO completed a sweep of the VA mouth. - 19:13: LEO placed a bag valve mask on the VA and took over life sustaining efforts from P1. - 21:21: An emergency responder entered the room and started assisting with the VA. Multiple other emergency personnel arrived shortly thereafter including Fire Department, Fire-Rescue, Paramedics, and additional LE. Emergency personnel continued to assist the VA until s/he was carried out of the facility at the 31:39 minute mark. LE records provided the following information: · LE was dispatched to the facility around 10:30 a.m., and observed the VA “gasp” for air while chest compressions were completed by P1, and LE placed a nasal airway and applied a bag valve mask to assist the VA with breathing. A “pulse ox” was attached to the VA’s right hand and showed the VA had a weak pulse, but did not register any additional information. LE applied an automated external defibrillator to the VA, but it did not advise a shock, but further medical care was requested. Once additional emergency personnel arrived they took over care of the VA. · LE completed an interview the SP, P1, P2, and P7, who provided similar information as observed in the video recording. · LE noted there were no signs of intentional neglect depicted in the camera footage. The SP was using a cell phone in the kitchen prior to the incident, however put away the device prior to the incident occurring. The SP believed the phone did not impact his/her medical response. The facility completed an Internal Review (IR) which provided the following information: · The VA had a swallow study completed in 2019 and there was no specific guidelines or restrictions regarding the VA’s food. The facility used a “best practices” technique to improve the VA’s ability to eat safely. The best practices included, but was not limited to, bite size pieces of food, checking the VA’s mouth while eating, and encouraging the VA to remain seated while eating. · The incident occurred between 10 and 10:30 a.m., on June 26, 2022, and the IR provided a similar description as stated above from the video recording. · The VA was transported to a medical facility, and staff persons were asked to leave the medical facility. The G provided the facility with updates, including that the VA would be removed from life support on June 27, 2022. · LE was provided the video recording and completed interviews with staff persons. · The SP provided similar information from the description above in the review of the video recording. · P1 said s/he was upstairs with the VA’s housemate and “thought” the VA was having a behavior, until the SP told him/her to get water for the VA. P1 attempted to help the VA and the SP prior to emergency personnel arriving at the facility as described above. · P2 heard the “commotion” downstairs, but was with the VA’s housemate and remained upstairs until s/he heard the SP and P1 yell for him/her. P2 contacted 9-1-1, and assisted in the care of the VA until emergency personnel arrived. · The SP said the VA was supposed to have “small bites” or have his/her food “cut” into “small sizes,” and had his/her mouth checked before having additional bites. The SP said the VA took a bite of the sandwich, and after the first bite the SP checked the VA’s mouth. The SP was not sure how many bites the VA had taken of the sandwich, but the video indicated the VA ate the sandwich in two bites. o Based on the video, the SP did not check the VA’s mouth prior to providing the VA the second bite, moreover the SP did not provide the VA with a drink prior to the second bite. · P7 was on shift, however not at the facility during the incident. · P5 said the VA needed bite size pieces of food, and staff could cut food or feed the VA. P5 spoke with the SP the day of the incident and the SP said s/he had followed the VA’s eating protocol, and was emotional after the incident. · The facility completed a staff meeting on June 28, 2022, in order to “debrief” all staff regarding the situation. Thereafter the facility completed a companywide all staff training highlighting the risks of vulnerable adults (including choking) and reviewed the facility’s policy and procedures. The facility also offered all staff the ability to be re-trained on chest compressions/First Aid prior to their renewal date. The facility completed an Incident Report which showed LE and the facility was unable to contact the G after the incident, however the medical facility made contact with the G and informed him/her of the incident. It was documented the incident occurred at around 10:30 a.m., on June 26, 2022. The SP provided the following information: · The SP said s/he “lived” the incident, and provided a similar description of events as observed in the video recording, and information from within the IR. The SP said “we” tried to do “everything” to help the VA during the incident, and the SP became emotional during the interview. The SP believed s/he had attempted to provide the VA with care and services as needed and how s/he was trained. · The SP said the VA liked peanut butter sandwiches and the SP had previously fed the VA in a similar fashion, with bite size pieces. The SP said it typically took the VA “two or three” bites to eat a peanut butter sandwich. The SP did not remember how many bites the VA took on the day of the incident, but said s/he had checked the VA’s mouth while the VA was eating. All persons interviewed, the G, facility staff persons P1-P2, facility supervisors P4-P6, the CM, and the SP, said the VA required bite sized pieces of food, and that s/he liked eating peanut butter sandwiches. The description of bite-sized ranged: · P1 made the VA’s peanut butter sandwich with two pieces of bread and peanut butter between the slices. P1 would cut the sandwich into eight pieces, and check the VA’s mouth after s/he had a bite. The VA was assisted with water/milk after eating the sandwich. · P2 made the VA’s peanut butter sandwich with one piece of bread, and cut it into two pieces. P2 provided the VA with the first piece, and provided the second piece after s/he ate the first. · P3 made the VA’s peanut butter sandwich with two pieces of bread and peanut butter between the slices. P3 would cut the sandwich in four pieces and tear those pieces in half to assist the VA with eating. · P4 said the VA needed a sandwich cut or torn apart, and estimated the VA ate sandwiches in ten bites. The P4 had previously held the sandwich in the same manner the SP held the sandwich on the day of the incident. · P5 said the VA’s food needed to be bite size, and staff were trained on how to feed the VA. Moreover, P5 trained staff on what “bite sized,” looked like and added “experienced staff” could hold onto the food while the VA ate. The VA’s daily log notes showed s/he ate peanut butter sandwiches multiple times in the days leading up to the incident. All staff persons completed training on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policy and procedures, CPR and First Aid, and on the VA’s specific programming prior to this incident. According to Redcross.org the following are the steps to perform Cardiopulmonary resuscitation (CPR): 1. CHECK the scene for safety, form an initial impression and use personal protective equipment (PPE) 2. If the person appears unresponsive, CHECK for responsiveness, breathing, life-threatening bleeding or other life-threatening conditions using shout-tap-shout 3. If the person does not respond and is not breathing or only gasping, CALL 9-1-1 and get equipment, or tell someone to do so 4. Place the person on their back on a firm, flat surface 5. Give 30 chest compressions - Hand position: Two hands centered on the chest - Body position: Shoulders directly over hands; elbows locked - Depth: At least 2 inches - Rate: 100 to 120 per minute - Allow chest to return to normal position after each compression 6. Give 2 breaths - Open the airway to a past-neutral position using the head-tilt/chin-lift technique - Ensure each breath lasts about 1 second and makes the chest rise; allow air to exit before giving the next breath - Note: If the 1st breath does not cause the chest to rise, re-tilt the head and ensure a proper seal before giving the 2nd breath. If the 2nd breath does not make the chest rise, an object may be blocking the airway 7. Continue giving sets of 30 chest compressions and 2 breaths. Use an AED as soon as one is available! Conclusion: On June 26, 2022, around 10:30 a.m., while eating a peanut butter sandwich the VA started to choke. Staff started life sustaining measures, and 9-1-1 was contacted. Emergency personnel arrived at the facility and continued the life sustaining measures. The VA was transported to a medical facility and received medical care thereafter; however the VA passed away as a result of the incident. Prior to the incident the SP was providing 1:1 care/services to the VA and a video recording captured the incident. During the video the SP and P1-P2 attempted to assist the VA during the incident. The incident started after the VA ate a peanut butter sandwich, which was being held by the SP, in two bites. After the second bite the SP started preparing a second sandwich and poured the VA a glass of milk. At that time, the VA made a quick movement, got up and left the area. The SP immediately and continually followed the VA and attempted to assist the VA and attempted to complete life sustaining measures including, but not limited to the Heimlich maneuver, and chest compressions. P1-P2 also attempted to assist the VA prior to emergency personnel arriving at the facility. Although the VA unfortunately passed away, for the following reasons, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services: · The video recording showed prior to the incident the SP used his/her cell phone, to which the SP said s/he was playing music. Based on the information, it was unable to be determined if the use of the cellphone distracted the SP and/or disrupted the care provided to the VA. · The VA did not have a specific plan ordered by a physician regarding his/her food. However, the facility had a best practices or rules related to assisting the VA with meals. The best practices included food being provided in “small manageable bites,” while staff was next to the VA, and directing the VA to take one bite at a time. Moreover, sips of water should be provided between bites of food. The best practices minimized the VA’s risk of choking, however did not eliminate the VA from harm while eating. o The facility staff provided slightly different descriptions for the term “bite sized,” including the sandwich being cut into smaller pieces than what was provided during the incident (two bites); however information also showed the VA had previously been provided peanut butter sandwiches in a similar fashion to that which s/he was provided on the day of the incident. o There was no definition within the VA’s documentation which showed or classified what “bite size” was regarding the actual size of the food. o During the video recording the SP observed the VA multiple times while the first bite of the sandwich was being chewed, but the SP did not provide the VA a drink after the first bite of the sandwich or check the VA’s mouth after the first bite. After the second bite the SP poured the VA a glass of liquid, but the incident started prior to the VA taking a drink. The SP attempted to provide the VA with a drink after the VA appeared to be in distress, and while attempting to assist the VA thereafter. o The SP was positioned next to the VA prior to the start of the incident and was within close proximity to the VA for the duration of the incident. The SP held the sandwich between each bite, and was observing the VA continuously. · The VA showed signs and symptoms which required an emergency response and the SP and P1-P2 took immediate action. o The SP immediately attempted to assist the VA and continued to try and provide the VA with care and services, including life sustaining measures. Moreover, P1-P2 responded to the incident and assisted with life sustaining measures, and contacted 9-1-1. o Emergency personnel arrived to the facility after ten minutes, and started providing care to the VA thereafter. o P1-P2 and the SP attempted to provide the VA with life sustaining measures, and although the steps in which CPR/chest compressions, and abdominal thrusts were completed did not specifically follow their training and/or the description from Redcross.org, the actions taken by the SP, and P1-P2, were done so within the VA’s best interest and care. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined the facility’s policies and procedures were adequate, and followed. The facility re-trained all staff on common risks of vulnerable adults, which included choking. The report was similar to past events as the VA had a history of choking and a previous swallow study was completed in 2019. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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