Incident investigation·April 10, 2023

LIcensing Program Analyst (LPA) Ana Soto conducted an initial case management visit to the above facility. LPA met with Amy Adam, RN and the purpose of the visit was explained. LPA interviewed RN, R#1 was on many different medication and NP was working with R#1 to minimize and adust medications. R#1 got very aggressive with S#1 and S#1 could not control or calm R#1 down. S#1 was fine did not sustain any injuries. Family member was called and advised of R#1 aggressive behavior and that they would be calling paramedics and Police Department for possible 51/50 hold. Police Officers could not place R#1 on a 5150, because of his mental condition and age. R#1 was taken to Torrance Memorial Medical Center. R#1 never returned to facility, R#1 stayed at the hospital. Family came to the facility to inform them that R#1, was placed on hospice at the hospital and had passed away on 02/08/23. LPA obtained the following records: Medical notes from NP, In-house incident report, Medication, list, Physician's report, Pre -Admission agreement form, Preplacement appraisal, and ID/Emergency information, An exit interview conducted with Amy Adam, RN and copy of report provided.