Incident investigation·July 21, 2021

LPA conducted a case management-incident report visit and arrived at 2:35 pm. LPA was greeted by Administrator Designee, Tannya Quezada. LPA observed staff wearing a mask upon entry to the facility. LPA explained the purpose of the visit was to speak to Administrator Designee regarding three incident reports. LPA Spaeth stated would like to review residents' files and speak to staff members regarding incidents. LPA reviewed records from 2:45 pm until 3:25 pm. Two reports stated two residents were AWOL from the facility. LPA Spaeth requested Administrator Designee to explain procedure staff follow when resident is AWOL. Administrator Designee stated Caregivers complete the following room checks each evening: 7:00 pm, 9:00 pm and 12:00 midnight. All residents' rooms are thoroughly checked. A 3:00 am check takes place where residents who need adult diapers to be changed. Administrator Designee also stated residents' rooms are also checked at 3:00 am who have previously eloped from the facility. Also, the night shift staff check every room at 7:00 am. If a resident is missing during room checks, caregivers will search the entire facility. If resident cannot be found, staff will called Administrator Designee, call 911 and search in cars the neighborhood. Administrator Designee confirmed residents menteind in the incident reports were found. Administrator Designee has implemented additional checks to be completed throughout the day for the residents who previously eloped from the facility. LPA Spaeth spoke to Administrator Designee regarding incident report stating on July 18, 2021, a resident was found by a caregiver with a metal hanger around resident's neck. Caregiver immediately tried to remove hanger but could not remove the item. Caregiver called another staff member who was able to remove the hanger. Administrator Designee confirmed resident was conscious but Administrator Designee was called and caregiver immediately called 911. Administrator Designee confirmed that resident is being treated in a hospital. Administrator Designee stated spoke to resident's clinician who stated when resident returns to facility, Clinician will be checking on the resident two times per week. Administrator Designee stated plan is in place for staff and Administrator Designee to frequently check on the resident once the resident is returned to facility. Administrator Designee also stated resident will be moved to a different room closer to the Administrator offices so all staff members can frequently check on resident. LPA concluded visit at 4:30 pm. Exit interview conducted, appeal rights discussed, and LPA confirmed a copy of the report will be emailed to Administrator Designee.