Incident investigation·March 15, 2024

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident reported to the department. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report/ death report dated 03/14/2024 indicated that on 03/08/2024, Resident 1 (R1) came into the facility from the patio with a cut on the left eye. The cut had a small amount of blood. Caregiver immediately called Administrator and began to clean the wound. Administrator contacted R1's wife who arrived at the facility within minutes with Administrator on the way to facility. R1's wife decided to drive the resident to Kaiser for assessment. Upon leaving the facility with the resident, R1's wife decided to call 911 instead and returned to the facility. Resident was examined by paramedics and was transferred to Mission Hospital where the resident passed away the next day. Per resident's wife, resident passed from a brain bleed. Administrator has provided a copy of the incident report to the Coroner. Per physician report dated 12/07/2023, resident is diagnosed with Dementia. Appraisal Needs and Services dated 12/27/2023 indicates resident walks without any assistive devices. Interview with staff indicates resident would frequently walk throughout the day and the resident had no prior falls. Licensee to obtain a copy of the death certificate and forward to LPA. Exit interview conducted and a copy of this report was left at the facility.