Incident investigation·June 8, 2022

On 6-8-22 at 2:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident occurring on 3-13-22. LPA met with Patricia Olvera, Business Office Manager, and explained the purpose of the visit. Administrator Mary Margaret Chappell was made aware of LPA’s visit and purpose. LPA reviewed physician’s report and service plan for resident1 (R1). LPA also reviewed incident report dated 3-16-22 regarding R1. Additionally, LPA interviewed R1. LPA also tested emergency response testing system during visit. Based on record review and interview it was determined that on 3-13-22 at approximately 1:00am, R1 sustained a fall and was sent to the emergency room and returned with a femur fracture. Interview with R1 revealed R1 pushed emergency pendent after she attempted to get out of bed to use restroom, and staff responded to pendent within 5-10 minutes. Resident was then found on floor and was sent to emergency room by facility staff via 9-1-1 call. Interview with R1 also revealed appropriate staff are available to meet R1’s needs and response time to emergency pendant is adequate. An additional interview with R2 revealed appropriate staffing levels are consistent to meet needs. LPA tested emergency pendent response time in the presence of Patricia Olvera and response was within 10 minutes. Review of physician’s report and service plan for R1 determine that both documents are updated to reflect R1’s current needs. No deficiencies cited during today’s visit. An exit interview was held with Patricia Olvera and a copy of this report was left with Patricia.