Incident investigation·July 16, 2024

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit to follow up on an incident report dated 7/13/24 and SOC341 dated 7/15/24. LPA met with Lisa DiBartolo (Administrative Assistant). Per incident report, on 7/13/24 resident (R1) approximately at 4:15pm went in another resident's (R2) room, staff redirected R1 to leave the room, but R1 was aggressive and hit R2 twice on their back and attempted to hit staff. Facility staff called 911 and EMTs determined that R1 needed further assessment at the hospital. Per discharge documents provided by the facility, R1 was seen for altered mental status and discharged with a diagnosis of hypernatremia, which is an electrolyte disorder. There were no new or change of medications order. Responsible parties were notified. During today's visit, LPA have reviewed R1's physician report dated 3/12/24, who has a diagnosis of Dementia. After this incident, the facility have developed a plan of action including assessment of R1's behavior, communication and engagement of their responsible parties along with facility staff, implemented person-centered care to meet R1's needs, provide additional staff training including managing techniques, perform continuous evaluation of the effectiveness of implemented strategies. LPA was also provided with written request submitted by the facility to R1's physician dated 7/10/24 at 4:59pm, 7/11/24 at 1:12pm and 7/15/24 at 9:33am requesting medication review and possible adjustment to address R1's aggressive behavior without receiving any response from their physician as of today yet. LPA will review documentation received to determine if further action is needed. No deficiencies cited during today's visit. Exit interview was conducted with Administrative Assistant and a copy of this report was given.