A review of a law enforcement incident report noted that S1 reported that at approximately 3:00 p.m. R1 was in the dining room and observed eating and interacting with staff. R1’s caregiver, Staff 2 (S2), later transported R1 to their room. Once back at the room, S2 noticed R1 unresponsive and immediately informed S1. Emergency services was contacted via 9-1-1.

Interviews with facility staff were conducted and the following was reported. S1 reported that on 10/27/2023, R1 appeared to be at baseline. Later that day, S2 informed S1 that R1 was unresponsive. S1 responded to R1’s bedroom and observed R1 slumped over with their dentures slightly displaced. S1 denied serving R1 solid food and reported that their duties primarily involved medication management and documentation. S1 further reported that they did not observe any food particles around R1’s mouth.

A review of a law enforcement incident report noted S2 stated to law enforcement that S2 gave R1 a snack at 3:00 p.m. At around 3:20 p.m., S2 observed R1 slumped in their wheelchair and appeared to be sleeping. S2 moved R1 to into their bedroom and asked if they (meaning R1) needed assistance lying on the bed. It was at this time, that S2 observed R1 unresponsive and immediately called S1 for help.

Regarding the allegation, “Staff are covering up violations at the facility” it was alleged that staff moved R1 to their bedroom following an incident and S3 instructed staff to say R1 passed away in their bedroom which was incorrect.

A review of video footage and interviews were conducted. The incident in question is the same incident noted above.

During interviews the Department was given conflicting information on whether R1 had partially eaten their snack or had not eaten the snack provided at around 3pm. Interviews with various staff also revealed conflicting information regarding why R1 was moved from the common area. Multiple staff initially indicated they believed R1 to be sleeping and this is the reason for taking R1 to their bedroom. While a subsequent interview revealed a staff reported that R1 was taken to their bedroom to maintain their dignity and avoid other residents from seeing R1 in distress.

S3 was interviewed and reported that on 10/27/2023, S3 was in a meeting when they received a call from S1 requesting their presence regarding an incident with R1. S1 directed S3 to R1’s room where R1 was observed unresponsive.

Attempts to conduct a subsequent interview with S3 were not successful. S1 reported S3 never instructed staff to move R1 to their room.

The allegations are unsubstantiated due to the evidence not meeting the preponderance of evidence standard. An exit interview was conducted and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to BOM.

A review of video footage was obtained. The video revealed S1 reported that at 3:02 p.m., they observed R1 interacting and speaking with S1’s son in the dining area. S2 provided R1 with a snack and R1 was eating their snack. S2 then reportedly observed R1 slumped and their snack was half eaten. S2 believed R1 was sleeping and wheeled to R1 to their bedroom to assist transferring them to bed. S2 then observed R1 to be unresponsive and contacted S1 for assistance. S1 observed R1 drooling from their mouth and reported the incident to their immediate supervisor, Staff 3 (S3). S3 checked R1’s pulse and emergency services were activated.

S2 reported to local law enforcement that at approximately 3:00 p.m., staff served snacks to the residents. S2 observed what appeared to be R1 sleeping in their wheelchair in the living room and left a snack for them on the side. At approximately 3:20 p.m. S2 observed R1 slumping and wheeled them to their bedroom. S2 called R1 by their name and asked them if they wanted to lie down. However, R1 did not respond or move. S2 described lowering their torso and tilting their head to observe R1’s face and observed that R1 appeared pale, with halfway open eyes, and purple lips. S2 then ran to S1 to report R1’s state of condition.

Responding ambulance personnel reported R1 was sitting in a wheelchair inside their bedroom upon their arrival. Ambulance personnel laid R1 on the floor and were presented with a Do-Not-Resuscitate order therefore life saving measures were not performed and they declared a time of death. The ambulance personnel are asked if they noticed anything by local law enforcement, to which the response was “No”. The coroner’s office is contacted by local law enforcement. The coroner’s office asks if there is any trauma, injuries, vomit, or anything suspicious to indicate R1 choked on anything, to which local law enforcement responds, “No”. Local law enforcement is advised the coroner’s office will not be responding to the facility.