Incident investigation·January 16, 2025

LPA K. Nguyen conducted an unannounced case management visit due to an unusual incident report (UIR) to CCLD received on 1/8/25. LPA met with Executive Director (ED), Connie Kuhlmann and explain the purpose of the visit. LPA interview S1 regarding the unusual incident report received on 1/8/25 regrading R1 got admitted to the hospital due to R1 have no urine output. S1 stated that when R1 was admitted to the facility R1 had this problem before. We have caregiver check on R1 twice a day and develop a routine for R1. Any unusually that R1 have with R1 catheter or urine coloration need to informed med-tech right away and sent them to the emergency right away. S1 spoke with R1 daughter and confirmed that R1 is doing okay, but R1 is still weak and is still recovering. LPA reviewed R1 physician report and needs/ service plan showed that R1 have a second diagnosed with urinary retention requiring foley catheter. S1 will update R1 needs and service plan when R1 return to the facility. No deficiency issue on today date. Exit interview conducted and copy of this report provided to ED, Connie Kuhlmann.