Incident investigation·February 16, 2024

On 2/16/2024 at 2:40pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived unannounced to conduct a Case Management visit for an incident that occurred on 2/16/2024. LPAs met with Scott Shahade, Executive Director (ED), and explained the purpose of the visit. While LPAs were conducting a continuation for an annual visit LPAs were informed by the ED that an incident occurred at approximately 6:00am this morning between Staff 2 (S2) and Resident 1 (R1). ED stated S2 was trying to prevent R1 from eloping, words were exchanged, and S2 pushed R1's walker causing R1 to fall. R1 was taken to the Sutter hospital. S2 was suspended pending investigation. Around 2:30pm LPAs were informed that R1 sustained a fracture and had returned to the facility. LPAs obtained a copy of the incident report, the SOC341, and discharge summary visit. For S2 LPAs obtained training records, application, and contact information. For R1 LPAs obtained admission agreement, hospice care plan, physician's report, identification and emergency contact, progress notes, and last assessment. Exit interview conducted. A copy of this report and appeal rights provided