Incident investigation·April 18, 2023

On 4-18-23 at Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a receipt of a death report. LPA met with Beatrice Clark and explained the purpose of the visit. LPA reviewed death report received on 3-30-23 and updated on 4-4-23 which revealed resident1 (R1) passed away on 3-25-23 due to lewy body dementia. LPA reviewed death certificate for R1 which revealed lewy body dementia as a cause of death. Based on interview conducted with Administrator, R1 was experiencing shortness of breath on 3-25-23 at approximately 12:30pm and 911 was called in under approximately 1 minute. R1 was not on hospice at the time. Based on interview, it was determined that a hospice referral was considered when admitted to facility 2-4-23 but ultimately was not made as R1's condition began to improve. Administrator called hospital to inquire about condition and was told at 1:48pm that R1 passed away. As a result of today’s case management, no citation is issued. An exit interview was conducted with Beatrice Clark and a copy of this report was provided to Beatrice.