Incident investigation·January 18, 2022

Licensing Program Analysts (LPAs) Melody Brown and Rohit Lama conducted an unannounced visit to the facility to conduct a case management visit to address an incident involving the death of Resident One (R1). The Department received an incident report from the facility 01/14/2022 regarding the R1's death on 01/14/2022. A Special Incident Report (SIR) details the resident, on 01/14/2022, was found in shower, down on his buttocks and back. The report details facility staff seeing water leak in front of R1’s room and when staff entered the room, staff found R1 unresponsive, down on his buttocks and back and contacted emergency medical services (911). A review of records revealed R1 had hypernatremia, peripheral edema and foot pain-swelling and was under Home Health Care for which medication was prescribed and the prescription completed. In addition, R1 have diagnosis of Aggressive behavior, Heart Failure with reduced ejection fraction (HCC), automatic cardioverter/defibrillator present (AICD), paroxymal atrial fibrillation (HCC) and traumatic brain injuty (TBI). LPAs reviewed medications and MARS, and observed the medication and initials on MARS matched. No follow up medical appointment was scheduled due to R1 under Home Health Care. Staff interviews corroborated the summary of events reported in the SIR and Death reports. Administrator Garcia will send LPA Brown a copy of the death certificate once available. No information was received by the LPAs to indicate there was any lack of care and/or supervision. No citations have been issued at this time. This report was reviewed with Administrator Michael Garcia and a copy provided.