Incident investigation·February 15, 2024

On 2/15/2024 at 1:50 PM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit to clarify/ gather information upon an incident report that LPA received on 2/06/24. LPA met with Administrator, Elizabeth Carson and explained the purpose of the visit. LPA reviewed and obtained R1 after visit summary. LPA interviewed S1 regrading of the incident that led to R1 hospitalization. LPA reviewed R1 MAR. S1 stated R1 develop a cough on 2/2/24 doctor prescribed PRN. Staff was instructed to give med to R1 as prescribed by R1 doctor. On the day of 2/6/24 R1 daughter came to visit R1 was doing well. Around 7PM R1 was reported by a staff member that R1 wasn’t doing well. R1 daughter was notified and R1 sent out to the hospital. R1 had returned to the community with new med changes as well as diet change. R1 is now on home health. S1 spoke to R1 daughter and R1 daughter do not have any question regrading R1 condition. No deficiencies issued during the visit and a copy of this report is provided via email.