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25 | Licensing Program Analysts (LPAs) Ruth Martinez and Dwayne Mason Jr made an unannounced visit to the facility to conduct a case management to follow up on information regarding a client’s death. LPAs arrived at facility was greeted and granted entry into the facility by Shawn Malone, staff. LPA Martinez spoke to Tim Gue, Administrator via telephone call and LPA explained the nature of the visit. Tim Gue, Administrator arrived at a later time and met with LPAs.
During the visit LPAs toured the physical plant of the facility, review of client files completed, review of staff files completed, and review of facility file completed. LPAs conducted interviews with staff regarding the death of client 1 (C1) who passed away on November 13, 2023. LPAs obtained copies of pertinent documents. LPAs interviewed staff for further information regarding the death of C1 and the events that led up to C1’s death. Per staff there was no indication that C1 had been having issues at the time and C1 was getting ready to watch the Monday night game in the living room. At the time of incident all clients were present, along with a direct service professional and Administrator. C1 was walking to bedroom when C1 fell in the hallway, Administrator immediately conducted CPR on C1. Direct service professional immediately called 911, paramedics arrived at facility and took over the care of C1 and transported C1 to local hospital for evaluation. The administrator received the information for C1 passing while at the hospital. Administrator notified all required parties LPA obtained information for collaborating agencies to the incident and contact person involved to request further information if needed.
No deficiencies were cited during this visit.
An exit interview was conducted, with Administrator and a copy of this report was provided and left at the facility. |