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25 | On 5-15-24 at 1:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding a previous department investigation of a death of a resident. LPA met with Licensee Maria Linda Estrada and explained the purpose of the visit. During this investigation, the department reviewed facility file documentation including physician’s report for resident1 (R1), medication records for R1, appraisal needs and service plan for R1, professional notes for R1, incident report dated 12-4-23, and death report dated 12-4-23. Additional documentation reviewed included death certificate for R1 and hospital records for R1.
Based on record reviews, it was determined that on 12-2-24, R1 approached staff1 (S1) with complaints of difficulty breathing. Immediate action was taken by S1 who called 911, and R1 was admitted to the hospital. Hospital performed services based on R1’s complaint of shortness of breath. On 12-3-23, R1 was moved to coronary care unit and discovered to have been unresponsive without a pulse. Cardiopulmonary resuscitation was started where a pulse was regained, but after a prolonged effort R1 past. Death Certificate documented that R1’s immediate cause of death was cardiac arrest, acute hypoxemic, hypercapnic respiratory failure, acute respiratory acidosis, and chronic obstructive pulmonary disease with exacerbation. Condition prior to or contributing to death was that R1 was admitted to local hospital on 12/02/2023, and R1 had a medical history of hyperlipidemia, hypertension, congestive heart failure. Additionally, a review of records indicates R1 was receiving hospice services and there was no questionable circumstance surrounding R1’s death.
As a result of this investigation, no citations are issued, and this case management is closed. An exit interview was conducted with Maria Linda Estrada and a copy of this report was provided to Maria. |