Incident investigation·October 5, 2023

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit regarding incident report submitted to the department on 10/2/23. LPA met with Brianna Goodlet and explained the reason for the visit. On 10/2/23 an incident report was submitted to the department, reporting Resident #1(R1) was asking for help on the memory care unit (MCU) courtyard and stated to have jumped from R1's bedroom window. On 10/3/23 LPA Flores contacted Erin Mahoney Executive Director who provided additional information over the phone and requested the following documents: Physician's Report, Needs and Care Plan, Identification and Emergency Information sheet, and medication sheets for the last three months. During this visit LPA Flores interviewed 3 staff, observed the physical plant of the incident, and reviewed R1's file. Interviews conducted revealed, On 10/1/23 R1 who resides in the second floor as an assisted living resident, was heard calling for help in the alleyway outside to the MCU dining room. R1 was observed engaged in activities earlier on the day and right before the incident had spoken to other residents right before dinner. R1 jumped off the window in the physical therapy room located across the second floor the elevator, closest to activity room. Per staff R1's personal belongings were found in the room and the screen of the window was removed and placed inside the room. At around 6:00pm staff in the MCU dining room heard R1 calling for help. Staff called Med-Tech in charge, who observed R1 on the floor and R1 stated to have jumped off the window in an attempt to hurt self. Med Tech called paramedics, who arrived shortly after and transported R1 to the hospital. R1 stated to staff that R1 had jumped from the window. Family representative, and Brianna Goodlet were contact to informed of the incident. Documents reviewed revealed; physician's report dated: 7/7/23 R1 does not note R1 to have a history of confusion, inappropriate behaviors, depression, or suicidal tendencies. Pre-placement assessment and skill nursing discharge notes do note depression. There are no notes of history or attempts of suicide. Medication sheet notes R1 has been taking medication as prescribed. No indications/suicidal thoughts were noted or observed within the last two weeks. R1 is currently hospitalized. No Deficiencies are being noted during this visit. Exit interview was conducted with Brianna Goodlet and a copy of this report was provided.