Incident investigation·January 28, 2025

01/28/2025 01:00 PM Licensing Program Analysts (LPAs) Rebecca Knight and Kayla Adkison conducted an unannounced case management visit and met with administrator Nicole Braswell. Today’s visit is regarding an incident report that was submitted to licensing on 01/21/2025 regarding an incident that occurred the same day at 4:00 AM. It was reported that a shift supervisor reported to administrator that a care staff had turned motion detector sensors away from the beds of residents who are at risk of falling. This same staff left a high-risk resident on the toilet unattended after this staff person had been previously counseled to ensure that a staff was with this resident at all times. The same morning this staff left an all-purpose cleaner in the memory care kitchen area and the shift supervisor found a resident spraying the cleaner into their mouth. LPA reviewed first aid measures for the all-purpose cleaner which had been submitted with the incident report. The document states if the solution is swallowed the person should rinse their mouth and get medical attention if symptoms occur. Administrator stated the facility sent the resident to the ER for evaluation, poison control and the resident’s POA were contacted. The facility has ensured that the motion sensors in the residents’ rooms have been fixed. In order to prevent this from occurring again the facility has terminated the staff person. On January 23, 2025, the facility held an all staff meeting and reiterated the importance of keeping chemicals locked in a secured area when not in use, talked about high-risk resident care and interventions, and resident neglect. No deficiencies were issued as a result of today’s visit. A copy of the report was provided to administrator Nicole Braswell.