Incident investigation·February 2, 2023

On 2-2-23 at 1:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management on various incidents occurring between 11-16-22 and 1-25-23. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA reviewed the following incidents and related facility file documentation as well as conducted additional interviews: On 11-16-22, an incident report submitted by facility stated resident1 (R1) and R2 were involved in a resident to resident altercation in which R2 allegedly placed an object in R1’s mouth due to R1’s snoring episodes. Facility reported incident to department, local law enforcement, and ombudsman. R1 and R2 are own responsible persons. Interviews were conducted with facility nurse, R1, and R2. Based on interviews conducted, it was determined that residents are no longer sharing a room and interact adequately. Interviews also revealed that no injuries occurred. Furthermore, interviews revealed incident was denied by R2. Appraisal needs and service plans for R1 and R2 have been updated to reflect above incident and monitoring for residents needs. On 12-27-22, an incident report was submitted stating on 12-27-22, R3 was double dosed on medication Lasix. According to R3’s orders, R3 was to receive 40mg of Lasix, and received 80mg of Lasix. It was determined through interview with facility nurse that medication technician was new during the time of incident and has since been in-serviced on proper procedures for assistance with medication administration including six rights of medication. Interview and incident report also revealed that R3 was closely monitored for additional signs and symptoms. Additionally, facility contacted R3’s physician and responsible person. On 1-5-23, facility reported and incident occurring on 1-4-23 in which R4 experienced a behavior episode which included wandering into other resident rooms and hitting facility walls. Additionally, incident report states R4 also hit staff in the stomach as well as another resident in care. R4 is a resident of memory care. Facility reported incident to licensing department, ombudsman, responsible parties, and local law enforcement within regulatory time frames. {Cont. on 809C} Needs and service plan for R4 is updated to reflect behaviors with interventions in place including monitoring for increased behaviors. Based on interviews conducted with facility nurse, there have been no further episodes of behavior seen in R4. Facility will refer R4 to psychiatric services. On 1-8-23, facility reported an incident occurring on 1-6-23 in which R6 sustained a fall after becoming agitated during a shower assist by staff. Additionally, this report stated R5 sustained an unwitnessed fall on 1-7-23. Facility reported R5’s room contained alcohol and suspected R5 was intoxicated leading to her fall. R5 and R6 were transported to hospital. Additionally, responsible parties for R5 and R6 were notified of incidents. R5 and R6 returned from hospital without injury and no new orders. R5 and R6 are monitored by staff at this time for increased behaviors and potential injuries. Facility will refer R5 and R6 to psychiatric services. On 1-21-23, facility reported an incident occurring on 1-21-23 in which R7 engaged in aggressive behavior towards staff and residents. R7 is a resident of memory care. According to interview with facility nurse, R7 became verbally disruptive, including yelling at various staff and residents. Interview further revealed that due to R7’s behaviors, R7 was sent to hospital for further evaluation and staff and resident were not struck by R7. At this time, R7 remains in hospital attempting to be stabilized. Facility reported incident to responsible party and licensing department within regulatory timeframes. R7s service plan reflects interventions for behaviors. R7 has also been referred to psychiatric services for follow up. On 1-27-23 facility reported an incident occurring on 1-23-23 in which R8 was sent to local hospital due to discovery of an open area on the coccyx area. Based on interview and record review, facility ordered home health for further evaluation, but R8 requested to be sent out to the hospital for evaluation. Discharge orders reviewed revealed R8 was diagnosed with skin abscess and sent back to facility on 1-27-23 with home health services. On 2-1-23, home health services determined R8 to now have a stage 3 wound and facility arranged for R8 to be sent to local hospital for additional follow up and treatment on 2-2-23. Licensing department and R8’s responsible party were notified within regulatory time frames. On 1-25-23, facility reported an incident occurring on 1-25-23 in which R9 sustained a fall resulting in a closed fracture of left foot. Based on incident report, R9 lost balance in room and fell. R9 was sent to local hospital on 1-25-23 and returned same day with orthopedic follow up requested. Progress notes reviewed stated facility arranged an appointment with R9’s physician on 2-8-23 for purposes of receiving an orthopedic follow up based on insurance, however, R9 declined appointment. Next available orthopedic appointment available is 3-8-23 according to facility progress reports. R9 is noted as own responsible party. Facility sent report to licensing department within regulatory time frames. Staffing schedule reviewed revealed 7 caregivers on duty during the date and time of incident, including care giving department supervisor. As a result of today’s case management, citation are issued under Title 22, Division 6, Chapter 8. An immediate civil penalty in the amount of $250 is issued in addition to the citation due to repeat violation within 12-month period. An exit interview was conducted with Anuradha Saini and a copy of this report was given to Anuradha. Appeal rights provided.