Incident investigation·August 20, 2024

Licensing Program Analyst (LPA) Rankin conducted an unannounced case management visit in response to incident reports received for Resident 1 (R1). LPA met with Jonathan Roberts and explained the purpose of the visit. LPA interviewed staff and residents at the facility. R1 did not need assistance with care and was very independent. CCL received multiple SIRs for R1 in July 2024, alleging falls with injuries, but R1 refused medical attention initially. R1 did eventually agree to go to the urgent care , urgent care told R1 they needed to go to the hospital. Hospital staff, APS, and law enforcement were involved with R1’s case. Although R1 told the facility they fell, other agencies were told by R1 “they jump on my toes while assaulting me.” R1 also stated they had been sexually assaulted but did not provide any additional details or indicate it occurred at the facility, stating it was law enforcement’s job to investigate. Due to the lack of supporting evidence, physical evidence was not collected by the hospital or law enforcement and a case was not pursued. After hospital discharge, facility followed up with R1's physician to get R1 a urgent follow-up visit. Based on this visit R1’s physician wrote an order that R1 should be moved to a psychiatric facility. On 7/18/2024, the administrator and another staff witnessed R1 self-harming and causing injuries to themselves. R1 was transported to the hospital and will be discharged to a higher level of care. Documents collected during visit were Physician Report's for 2012, 2015, and 2023 showing R1's physician noting resident was able to manage their own medication. Facility respected R1's personal rights in wanting privacy regarding R1's independence. When a change in behavior was noted in 2023 facility requested the physician complete a new Physician Report, this did not result in a change in medication management, but facility did their due diligence in notifying primary care of concerns and initiating an updated medical review. Based on resident and staff interviews conducted, no citations were issued on this visit. Exit interview, report given.