Incident investigation·August 9, 2024

On 08/09/2024 at 1:50 p.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving an Unusual Incident Report (UIR) of a resident having attempted suicide. LPA met with Niare Feaster , Executive Director and explained the purpose of the visit. R1 was admitted to the facility on 9/29/23. Physician's Report dated 6/07/24 indicates that R1 was independent and could leave the facility unassisted. Report indicates that R1 was not at risk of accessing personal grooming supplies. The report also documented that R1 did not have any suicidal ideations. ED stated that R1 had 2 cuts about 1 inch each and that the cuts did not require stiches. Resident is still on a 5150 hold and has not returned to the facility. R1 refused to be transported to the hospital and received first aid from the EMT's. RP was notified of incident and came to the facility to speak to ED and at that time R1 admitted that the cuts were self inficted and that they planned on doing it again. ED notified law enforcement and R1 was 5150 when EMT's returned. R1 is to be reassessed before returning to the facility. RP and ED will determine the best course of action and develop a new care plan as needed. Health and Wellness Director filed an UIR and informed LPA via phone of the incident. LPA toured R1's room with S1 and observed it to be within regulation standards. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.