TOMBALL, TX – LAWRENCE STREET HEALTH CARE CENTER

Based on observations, interviews, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 6 residents (CR #1) reviewed for supervision.

The facility failed to supervise CR#1 while he ate a snack in his room. CR#1 was identified as being high risk for choking and died of asphyxiation after being left unsupervised.

This failure affected 1 expired Resident.

Record review of Facility completed DADS 3613-A Form dated and signed by the Administrator on [DATE] revealed Incident Category Death, Description of the Allegation After completing staff interviews and speaking with the ME, it has been determined that CR#1 was provided a peanut butter and jelly sandwich for his snack, which was suctioned from his airway at the hospital, where he expired. Investigation Summary CR#1 had taken his evening medications without difficulty. The CNA assigned to CR#1 was interviewed the following morning and she stated that she offered him a variety of bedtime snacks and provided him a peanut butter and jelly sandwich which he requested. CNA returned to his room to pass hydration and discovered CR#1 to be unresponsive. CR#1 expired at the hospital. According to the ME who called the following day, peanut butter was suctioned from CR#1’s airway. The facility finds the investigation of Death to be confirmed.

Interview on [DATE] at 12:00 p.m. with Administrator and DON revealed they both were notified by LVN K on [DATE] after 9:00 p.m. about sending CR#1 to the hospital for being unresponsive. Administrator stated that LVN K had given CR#1 his night time medications and ,[DATE] minutes later he was unresponsive and she remembered that it was not enough time to be a medication error and she asked LVN K what he thought happened. He said he thought the resident may have had a [MEDICAL CONDITION] and he was taken to the hospital Administrator stated that the next morning she was asking questions and investigating and found out he had received a sandwich and earlier that day we got a call from the ME who said the hospital had suctioned peanut butter from CR#1’s airway. Administrator stated that CNAs were to check the residents diets before giving a snack and at the snack cart has a daily updated list of residents on mechanically altered diets. She further stated that this system is their most solid system if she had to pick one.