Incident investigation·September 9, 2022

During Licensing Visit at 10:30 AM LPA spoke with the facility staff and residents. Information received revealed the following; On 09/07/2022, R1 was last seen by their roommate resident #2 (R2) roughly fifteen minutes prior to the incident, around the dinner time. R2 went for dinner and R1 did not wish to join R2. R2 grabbed dinner and returned to their room and needed to use the restroom, knocked on the door several times, and when R1 did not respond R2 opened the door saw R1’s feet outside of shower curtains. R2 alerted staff, and they found R1 hanging from the shower head using a belt. R1 was unhooked, staff called 911 and began CPR as they waited for paramedics to arrive. Paramedics arrived and resumed CPR but with no results. Police arrived, took the belt and corners arrived shortly after. The family of the deceased were notified, and responsible member stated that R1 had a previous incident. During this visit at 11:30 AM, LPA requested and reviewed R1’s facility records. A review of records revealed that R1 had Mental Health problems and needed medication assistance. R1 did not require any assistance with other Activities of Daily Living (ADL) and was able to leave facility unassisted, able to care for personal needs and had no suicidal ideation. LPA Duguma was informed that the Administrator has contacted a psychologist to speak with staff and residents. No immediate health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.