Incident investigation·July 6, 2023

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced case management visit to follow up on incident report submitted to the department on 6/30/23. LPA met with Virginia Garcia administrator and explained the reason for the visit. On 6/30/23 facility submitted incident report regarding resident #1(R1). On 6/26/23 R1 sustained a fall during an episode of seizure while taking a shower. At the time of the incident R1 was evaluated by supervisor. After the seizure R1 was in sleep state and unable to communicate symptoms. Per wellness director, hospice was contacted. A nurse arrived to evaluate R1 within 30 minutes of incident, and verbally provided recommendations for R1. On the morning of 6/27/23 caregiver went to assist R1 and noticed R1 was moaning. Facility contacted hospice and responsible party at that time. On 6/27/23 hospice requested a x-ray. On 6/28/23 x-ray was conducted and revealed R1 sustained a subcapital fracture of the femoral neck to the right hip. Per documents reviewed, R1 was admitted to hospice after "an episode of seizure" on 2/2/23. Last physician report was conducted by hospice doctor on 6/22/23. R1 is currently on comfort care under hospice at the facility. LPA requested copies of physician's report dated 6/22/23, hospice care plan dated 2/2/23, verbal orders dated 6/27/23, physician's order dated 6/26/23 and 6/29/23, hospice communication sheet dated 6/22, 6/26,6/27,6/29/23, x-ray interpretation dated 6/28/23, hospital discharge dated 1/28/22, hospice initiation letter dated 2/2/23, and unusual incident report dated 6/29/23, appraisal/needs and service plan dated 6/22/23, advance health care directive dated 3/1/10, and medication sheet for July 2023. Facility staff is following hospice care plan and healthcare designated agent's request to provide comfort care for R1 and is currently updating appraisal/needs and service plan. No deficiencies were noted during this visit. Exit interview was conducted with Virginia Garcia administrator and a copy of this report was provided.