Incident investigation·December 9, 2022

On 12/9/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for an incident report and LIC 624 and LIC 624A. LPA Jensen met with Licensee Elizabeth Abesa and explained the purpose of today's visit. LPA Jensen interviewed licensee for a timeline of events. On the date in question, Resident 1 (R1) was acting normally. On this date her case manager had called between 2pm and 3pm and staff advised that R1 was doing fine. On this date R1 had been observed engaging with other residents and at dinner at approximately 4pm with no unusual activity or behavior observed. The facility charts any unusual activity such as decreased appetite etc... On the date in question there was an entry related to incontinence however this was not an unusual occurrence. Medication pass is typically done around 6pm. Between 5:45 and 5:55pm, the medication technician found R1 found to be unresponsive in bed. The medication technician attempted to arouse the patient unsuccessfully, called the Licensee who had just left the facility and was one block away. 911 was called at 5:57 by the medication technician. The ambulance responded within 5-10 minutes. The Licensee contacted the R1's family at 6:14pm. R1 was transported to the hospital by ambulance. The facility telephone logs times and dates of calls. Call times were verified by the telephone call history. Based on interviews conducted, file review and phone records the facility was determined to have fulfilled their required duties in a timely manner. No deficiencies are being cited as a result of this visit.