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25 | On 6-6-24 at 12:10pm, Licensing Program Analysts (LPAs) Michael Bilger and Avelina Martinez arrived unannounced to conduct a case management regarding an incident which occurred on 5-11-24. LPAs met with Administrator Melissa Patacsil and explained the purpose of the visit. LPAs reviewed incident report dated 5-12-24 and conducted brief interview with Administrator. Based on record review and interview, on 5-11-24 resident1 (R1) was sent to acute hospital due to required catheter care. Incident report stated R1 was admitted 5-11-24 for diagnosis of hypoxic respiratory failure due to pneumonia. It was further revealed that R1 has a restrictive care plan for tube feeding care and managed by facility's registered nurse (RN). Facility staff notified 911 within appropriate time frame after discovering leaking catheter bag. After arriving at hospital, it was revealed that hospital observed R1 gurgling and therefore, admitted R1 for pneumonia and treated. R1 completed antibiotic treatment at hospital and R1 returned to facility after treatment. Interview conducted also revealed that R1 has chronic coughing and gurgling due to tube feeding placement, and staff have been trained to observe and notify nurse consultant and Physician as necessary.
As a result of today's case management, no citations are issued. An exit interview was conducted with Melissa Patacsil and a copy of this report was provided to Melissa. |