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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.16 | Individual #1 had a diagnosis of dysphagia, Alzheimer's, dementia, acid reflux, apraxia of speech, and down syndrome. Individual #1 required a pureed diet, unless a food was naturally soft (for example: a cupcake, pudding, jello). Individual #1 also had a Choking Prevention Care Plan in place that was updated by their physician on 10/11/23 indicating that Individual #1 had signs and symptoms of choking/aspiration that were unique to Individual #1, including coughing, teary-eyed, and frequent throat clearing.
There were a total of 19 staff who worked in Individual #1's home between 9/1/23 and 11/11/23. Only 4 of these staff (staff persons #2, 6, 12, and 15) were trained in how to properly prepare Individual #1's pureed diet. Only 6 staff (staff persons #1, 3, 12, 13, 15, and 17) were trained on the 10/11/23 Choking Prevention Care Plan. Only 5 staff (staff persons #1, 2, 4, 15, and 17) were trained in Individual #1's Individual Support Plan. All 19 staff were trained in Dr. Cherpes' Health Alert.
On 11/11/23 at 4:00pm, staff person #1 served Individual #1 pork chops that were "in tiny bite size pieces, covered in BBQ sauce, small enough that it looked shredded" instead of pureed per their diet protocol. At 4:50pm, staff person #1 noted that Individual #1 finished their pork chops and began coughing, including coughing up spit. Staff person #1 patted Individual #1's back but did not provide any further medical attention. At 5:15pm, staff person #1 gave Individual #1 a drink, and the individual started to choke again, "like [they] couldn't get the water down." At 5:30pm, Individual #1 began breathing more heavily, tried to take a drink, started breathing more loudly, and their nose started to run. Staff person #1 contacted an agency point person when Individual #1's lips began to turn blue. 911 was not contacted until 5:40pm. Individual #1 was transported to Memorial Hospital, where they were sedated and put on a ventilator. Individual #1 passed away in the hospital on 11/22/23.
Despite being trained on Dr. Cherpes' Health Alert, staff person #1 delayed calling 911 for approximately 50 minutes, even when Individual #1 was showing the signs and symptoms of choking. Failure to properly train staff on Individual #1's health and diet preparation needs and a delay in seeking emergency medical care created conditions conducive to serious harm for Individual #1. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Train all staff on how to properly prepare individuals food and verify that staff know and are able to replicate what they are shown.
Update Incident Management Policy and train all staff on policy (Director, Training Coordinator, Incident Manager)
Update Orientation and Annual Training Policy and train all staff on policy (Director, Training Coordinator)
Update Health and Behavioral Emergencies and Crisis Policy and train all staff on policy (Director, Incident Manager, Training Coordinator)
Ensure that all staff are retrained on the 911 health alert and what to do in emergency situations (Incident manager, Training Coordinator)
Ensure that all staff are trained on an individual's plan, assessment, procedures, and protocols PRIOR to working directly with an individual. (LPN, PC, Training Coordinator, Assistant Training Coordinator, Residential Program Supervisors who have been trained by PS)
Update training documentation to better reflect the information that staff have been trained on.
All Supervisors were trained last week on all individual plans during the course of a two-day training
Train all staff on all individual plans, protocols, and procedures in three small group sessions (4 houses per session) in order to get all staff initially trained. This began 2/20/24 and 2/23/24 which will cover the first round of 4 house sessions. We will rotate these staff through the other two 4 house sessions which will end with all staff trained on all individuals. These trainings are scheduled for March 5th, 8th, 14th and 15th. |
02/23/2024
| Implemented |
6400.52(c)(6) | There were a total of 19 staff who worked in Individual #1's home between 9/1/23 and 11/11/23. Only 4 of these staff (staff persons #2, 6, 12, and 15) were trained in how to properly prepare Individual #1's pureed diet. Only 6 staff (staff persons #1, 3, 12, 13, 15, and 17) were trained on the 10/11/23 Choking Prevention Care Plan. Only 5 staff (staff persons #1, 2, 4, 15, and 17) were trained in Individual #1's Individual Support Plan. Additional staff signed a sheet indicating that they "read and understood" Individual #1's Individual Support Plan, however, in person training with the Individual physically present is required for this regulation. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Ensure that staff are trained in person with the individual present for a portion of the training (Program Specialist, Training Coordinator, LPN)
Ensure that staff are fully trained on each individual's plan, protocols, and procedures prior to working alone with the individuals (Training Coordinator, Assistant Training Coordinator)
Verify documentation of training prior to staff working alone with an individual (Training Coordinator, Assistant Training Coordinator, Program Specialist) |
02/23/2024
| Implemented |
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