Incident investigation·August 9, 2023

Licensing Program Analyst (LPA) Angela Hood arrived at the care home unannounced to conduct a case management inspection related to an incident report received by the Department. On 8/5/23, an incident report was received regarding a memory care resident (R1). On 8/1/23, R1 was observed to have a cough, chills, and 103.1 degree F fever. R1 was tested for COVID-19 and the results came back negative. R1 was transported to the hospital and was discharged with a diagnosis of severe sepsis with acute organ failure and UTI. R1 returned to the facility with a new medication order of antibiotics. During today's visit, LPA toured the memory care units and observed R1 in the activity room. LPA was informed that R1 does not have frequent UTIs. R1 has a Dementia diagnosis and experiences confusion. R1's fever was an indicator to the facility staff to have R1 sent to the hospital. Upon return from the hospital, R1 is back at baseline. R1 has a follow-up appointment scheduled with their primary care physician on 8/15/23. Facility staff provide R1 assistance with toileting needs and keep track of set times for assistance electronically. LPA obtained a copy of R1's service plan and electronic tracking of R1's toileting needs for the week of 8/1/23-8/9/23. There are no deficiencies noted during today's inspection. Exit interview was conducted. Copy of report provided to Executive Director.