1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 | On 10/28/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Representative (FDR), Christina Goforth and explained the purpose of the visit.
The purpose of this visit was to follow up on two Special Incident Reports (SIRs), that were received by the department on 09/16/2024, and 10/24/2024.
On 09/16/2024, the facility reported that at 12:00am, Medication Technician provided a resident with a higher dose than prescribed of PRN medication to the resident. It was stated that this resident was only to obtain half a tablet of rather than a full tablet. The facility provided this medication technician a corrective action plan and was provided an in-service training of the 7 rights of medication.
On 10/24/2024, the facility reported an elopement that happened on 10/22/2024 at approximately 2:00pm.
It was stated that R1 left the memory care area through the back door near the living room. As staff heard the door chime and reported to the back door, the resident was no longer in the area. Simultaneously, the facility staff at the front desk observed R1 near the front of the facility and was seen walking around. This facility staff went outside to redirect the resident back into the facility. The resident's family and hospice agency was notified of incident. LPA reviewed R1's physician report dated on 10/23/2024 states that the resident has a dementia diagnosis and cannot leave the facility unassisted. R1 has a documented elopement on 07/15/2024, where the resident was found an hour after elopement. R1's needs and services plan most recent personal service plan conducted on 07/30/2024 also indicates that R1 has episodes of wandering and if someone has the door open they will attempt to leave. R1's personal service plan also indicates that this resident needs redirection and a close eye due to wandering and exit seeking. The facility also noted that R1 needs to be continuously engaged to avoid her wandering.
Due to insufficient time to review additional paperwork and conduct other interviews, the department will follow up at a later time if warranted.
An exit interview was conducted. Due to printer issues, a copy of this report was provided to the facility at the end of this visit via email. |