Incident investigation·November 21, 2024

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced case management visit to follow up on an incident reported to Community Care Licensing.  LPA met with Brandon Cho, Executive Director, and discussed the purpose of the visit. On November 20, 2024, the facility updated the death report of Resident 1 (R1), age 99, to the Community Care Licensing Division (CCLD). The death occurred at the hospital post-acute skilled nursing facility (SNF), after hip surgery. The updated report included the cause of death that was not available to the facility at the time of death from the hospital on November 10, 2024. According to the facility’s written incident report, R1 experienced an unwitnessed fall on October 30, 2024, at approximately 4:42 am. R1 was transported to the hospital for medical treatment and underwent hip surgery on October 30, 2024. The facility reported that R1 passed away on November 10, 2024, the principal causes of death were Failure to Thrive, advanced dementia, and cerebrovascular accident (CVA); contributory causes were a recent hip fracture and chronic AFB according to the Death Record from the hospital. The facility was notified of the death from the Power of Attorney (POA) on November 11, 2024. . The Licensing Program Analyst (LPA) interviewed the Administrator and staff regarding the incident. The Administrator stated that staff followed the facility’s emergency protocols and contacted emergency services. Staff present during the incident confirmed that R1 was monitored per their care plan before the event. Review of Records: R1’s medical records indicated the resident was receiving physical therapy once a week for 5 weeks to address muscle weakness and balance disturbance having difficulty with standing. The primary diagnosis was Dementia, secondary diagnosis: was falls, neuropathy, AFB, and insomnia. R1 needed a wheelchair and was considered non-ambulatory per the signed LIC602A. The facility’s incident reports were submitted within the required timeframe and included all pertinent details. Observations of the facility revealed appropriate safety measures were in place; no environmental hazards were observed. Based on the information gathered, the facility appears to have acted appropriately and in compliance with applicable regulations regarding this incident. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to the Executive Director along with appeal rights (LIC9058 03/22) and an LIC 811