Incident investigation·December 10, 2021

Licensing Program Analyst (LPA) Michael Hood met with Senior Executive Director, Caroline Frangieh, to conduct a case management visit. The purpose of the visit is to follow-up on an incident report that was received by the Department. Prior to initiating the case management visit, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Incident report received by the Department states that, on 12/5/2021, Sutter Hospice Nurse observed resident (R1) enter the apartment of resident (R2), leading to a physical altercation between both of the residents. Both residents have a primary diagnosis of dementia and live in the Memory Care Unit of the facility. Resident's MDs and Power of Attorneys (POAs) for both R1 and R2 were contacted regarding incident. Neither R1 nor R2 have aggressive behaviors indicated in their needs and services plan. Care Notes indicated that similar altercations have occurred between R1 and R2 on 9/18/2021, 10/10/2021, and 11/14/2021. Each incident involved R1 entering R2's apartment, leading to an altercation that became physical. Care Notes indicated that MD and POAs were contacted for both R1 and R2 with each incident. Senior Executive Director stated that additional safety watch has been implemented for R1 and R2 to monitor residents' behavior to prevent R1 from entering R2's apartment. The facility will conduct a meeting with R1's family to discuss moving R1 to another apartment to prevent altercations since R1 and R2's apartments are next to each other. If R1 is unable to receive approval for a change of apartment or if change does not resolve pattern of behavior, than facility will seek 1-on-1 supervision for R1. No deficiencies are being cited at this time. Exit interview conducted and copy of report left at the facility.