Incident investigation·May 17, 2023

LPA Parks arrived on Wednesday May 17, 2023 to conduct a case management visit. LPA met with Administrator Haley and explained the purpose of the visit. This is a follow up visit for an incident that occurred on 5/13/2023. On Saturday May 13, 2023, front desk employee heard R1 yelling for help from outside the facility. Facility nurse and staff quickly went outside and observed R1 outside the front doors, to the left of the front pillar. R1 was observed to be on the ground, with their electric wheelchair on top of them. R1 was yelling 'get this chair off of me'. R1 refused to go to the hospital, denied hitting their head, and denied being in pain. Facility staff assisted the resident and wheelchair to an upright position. Facility nurse noted no visible wounds and R1 was speaking clearly. Facility nurse notified resident's DPOA of the incident and their refusal to go to the hospital. Approximately 10 minutes later, Facility nurse then observed blood in R1's catheter bag and R1 was complaining of bilateral ankle pain. R1 agreed to go to the hospital for evaluation. Administrator was notified later in the day, while at the hospital, R1 became short of breath and was subsequently put on a ventilator. Due to R1's advanced directives, resident was taken off life support at the hospital and passed shortly after. During today's visit, LPA reviewed the LIC624 and death report regarding this incident. LPA reviewed R1's physicians report, care plan, motorized chair assessment, and mini mental exam. LPA interviewed the Administrator, Wellness Director, and facility staff regarding the incident. LPA needs to interview three additional staff who observed the incident, but were not scheduled to work today. LPA obtained employee and DPOA contact information for interviews. Additionally, LPA obtained a copy of R1's advanced directive paperwork. No deficiencies cited. Exit interview conducted. A copy of this report was left at the facility.