Incident investigation·July 12, 2022

On 7-12-22 at 3:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to recently submitted death reports. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA reviewed death reports for Resident1 (R1), and R2 and accompanying documentation with Administrator. Death Report #1: Death report stated R1 was sent to acute hospital on 5/6/22 due to a fall and facility was notified or R1's passing on 6-10-22. LPA reviewed accompanying death certificate submitted by facility staff indicating R1 passed away due to Alzheimer's Disease on 6-1-22. Incident report relating to R1's fall was received timely on 5-7-22 and death report was received timely on 6/14/22. Death Report #2: Death report stated R2 was found unresponsive on 6-19-22 and passed away on the same date. and had a Do Not Rescussitate (DNR) on file. LPA interviewed Administrator regarding events prior to death. Based on interviews, it was determined that R2 was considered for hospice care by R2's physician, but unable to be admitted due to lack of responsible party signature for authorization per hospice agencies. It was further determined through interview that physician for R2 instructed facility to provide comfort measure in lieu of traditional hospice care. Death report was received timely on 6-23-22. No deficiencies issued as result of today's visit. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha.