Incident investigation·August 16, 2022

Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with Donald Stamets, Administrator. The purpose of this case management is to follow up on two self reported incidents reports submitted to Community Care Licensing (CCL) on 7/14/2022. CCL received a self reported incident report reporting on 7/5/2022 at 1:00 PM, nurse was summoned to resident’s (R1) room to assess for frequent coughing episodes with clear phlegm since lunch. Tested negative for COVID. While assessing resident nurse and care manager helped R1 to the restroom, while seated on toilet R1 suddenly slumped forward and was unresponsive. R1 was taken to Marin General Hospital (MGH) ER for evaluation and discharged same day with no new orders. Discharge diagnosis syncope. CCL received a second incident report on 7/14/2022 of an incident that occurred on 7/7/2022 at approximately 9:00 PM with the same resident (R1). Medication Care Manager (MCM) noticed resident having slurred speech, vitals taken BP 191/86, R1 was taken to MGH ER for evaluation and admitted for further tests. R1 returned 7/10/2022 with new medication orders and follow up with Dr. on 7/12/2022. Administrator and Wellness Nurse Singh advised LPA after R1 had medication adjusted there was no reoccurring issues with syncope and R1 has remained at baseline. No deficiencies cited during today’s inspection