Incident investigation·June 16, 2022

On June 16, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on incidents that were reported to CCLD. LPA met with Assistant Director of Health Services, Hazel Yabut, and explained the purpose of the visit. The Licensee reported that resident (R1) had three separate incidents; one on 5/27/22 and two on May 30, 2022. On 5/27/22, it was reported that R1 hit an agency caregiver (S1) in the face, causing both R1 and S1 to fall to the floor. In addition, it was indicated that during this incident, a second caregiver (S2) present was knocked to the floor after attempting to redirect R1. On May 30, 2022, it was reported that R1 touched a caregiver (S3) while giving R1 a shower in the morning. Later in the day, it was reported that R1 touched another resident (R2). During the case management, LPA interviewed staff and reviewed R1's file. According to the file reviewed and the interviews conducted, R1 is a newly admitted resident with a diagnosis of Dementia with behavioral disturbances. In addition, LPA reviewed R1's service plan and it indicates that R1's medications were adjusted, facility implemented frequent checks and has assigned R1 with two caregivers to be present when providing care. On 5/26/22, the licensee reported a male resident (R3) walked into a female resident's room (R2); no injuries were reported. During the visit, LPA observed the residents and reviewed R3's file and interviewed staff. According to file reviewed, R3 has a diagnosis of dementia. Interviewed staff indicated that R3 does not have any prior history of unusual behavior. Based on R3's needs and services, the facility implemented frequent checks to prevent this incident from happening again. LPA reviewed this report with the Assistant Director of Health Services, Hazel Yabut; a copy is provided