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25 | On 12/13/22 at 10:36 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced visit to the facility to investigate an incident reported by the facility. LPA met with Kirk Klotthor, Administrator, and explained the purpose of the visit.
On 12/11/22 at 8:53 pm, the administrator emailed an Unusual Incident/Injury Report (LIC 624) to the LPA. The Incident Report states that, on 12/11/22 at 4:25 pm, staff entered the room of Resident #1 (R1) and found R1 in their bed unresponsive. Paramedics were called, and per the administrator, R1 had committed suicide.
On 12/13/22 at 10:40 am, LPA toured R1’s room. It is a single occupancy room with a locked door. Administrator states residents who are able to lock/unlock their doors are given keys and that R1 was given a key.
At 10:45 am, LPA interviewed the administrator. The administrator states that he heard from his staff that R1’s family told staff that R1 had tried to commit suicide prior to residing in the facility and that helium may have been used. He states that the family wanted the resident in a locked facility due to R1’s dementia and that R1 couldn’t take care of themselves. Administrator states he was involved in the resident assessment prior to R1 moving in. Administrator states that R1’s doctor visited on 12/9/22 and assessed R1 to determine whether R1 did, in fact, have dementia. Administrator says it was a concern that was brought up either by R1 or the Long-Term Care Ombudsman and says that the doctor did not provide the new assessment or revised Physician Report (LIC 602) to the administrator.
At 11:40 am, LPA interviewed Staff #1 (S1). S1 states that R1’s family visited “often, at least five times.” S1 says the family wanted a better quality of life for the resident and that R1’s family said R1 had previously tried to commit suicide but did not foresee this happening again. S1 says the family did not provide specifics about the attempt. S1 says R1 was very jovial and engaged in facility events and a joy to have around.
Continued on 809-C.
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