Incident investigation·May 9, 2024

05/09/2024 9:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Jessica Owen administrative assistant and explained the purpose of the visit. Today’s visit is regarding an incident that occurred on 04/29/2024 and was reported to licensing on 04/29/2024 by the facility. It was reported that on 4/28/2024 Staff 1 (S1), Staff 2 (S2), Staff 3 (S3) went into Resident 2 (R2)’s room and found Resident 1 (R1) in the room. R1 to become agitated. R1 sat down at the foot of R2’s bed and then hit R2 on their feet. Report states S1 instructed S2 and S3 to restrain and remove R1 from the room. S2 placed their hands under R1’s arms and guided them out of the room. R1 became agitated. S1 stood in front of R2’s door preventing R1 from re-entering the room. R1 started yelling, screaming, and became combative. S1 called 911, Sheriff's Department responded and R1 was transported to Oroville Hospital and placed on a 5150 hold. Administrator in training contacted the psychiatrist on duty at Oroville Hospital. The psychiatrist made some medication changes, determined that a 5150 hold was not required, and released R1 back to the community. R1 was unable to remember any incident or recall the police incident. S1 was terminated as a result of the incident. During the course of the investigation, it was learned that staff guided R1 out of R2’s room in a safe manner. Law enforcement did transport R1 to the hospital and R1 was released back to the facility with updated medications. R1 was not injured as a result of the incident. LPA is requesting that the facility update the resident’s care plan to address the behavior and submit the updated care plan to LPA. The facility has provided care staff with training on de-escalation techniques to keep all residents safe. No deficiencies are being cited as a result of the investigation. Exit interview was conducted and the report was provided to COO Diania Bingham.