Incident investigation·September 3, 2021

On 9/3/21 at 10:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident that occurred on 8/5/21. LPA met with Administrator Morgan Whinery and explained the purpose of this visit. LPA reviewed the following documents: Resident1 (R1)'s service plan, hospital records, and previous incident reports. LPA also conducted interviews with Staff1 (S1) and S2. LPA also interviewed Day Program social worker for R1. Based on interviews with day program social worker, S1, and S2 and based on records reviews it was determined that R1 was at the day program on 8/5/21 and was sent to the emergency room (ER) after a registered nurse (RN) at the day program noticed a wound on R1's left leg with oozing puss needing attention. According to record review, RN sent R1 to ER for further evaluation of wound on 8/5/21. Based on interview with S2 and hospital record review, it was revealed that R1's wound was previously addressed by S2 on 7/12/21 and sent to ER for further evaluation and treatment. Based on interview with day program social worker it was revealed that day program attempted to call facility, but attempted the call using an phone number no longer in service and has since learned of the new phone number. As a result and based on additional interviews with S1 and S2, it was revealed that facility did not receive notification from day program on 8/5/21 that R1 had been sent out, and did not learn of R1's hospitalization until hospital notified facility of R1's time for discharge on 8/5/21. Upon further record review of incident reports, it was determined that an incident report for 8/5/21 was not received by licensing department until 9/3/21, and an additional incident report from 8/7/21 was not received by licensing department until 8/18/21. Based on today's visit, deficiencies are being cited under Title 22 regulations, Division 8. An exit interview and a copy of this report along with appeal rights was left with Administrator Morgan Whinery.