Facility Evaluation Report

On 8/11/2023, at 9:00 AM. Licensing Program Analyst (LPAs) L. Fici arrived unannounced to conduct a Case Management Visit. LPA was greeted by Rosalinda, Amacan, Administrator (ADM) and explained the purpose of today’s visit.

LPA received an incident report which occurred on 6/20/2023, regarding a death in the facility. During visit, LPA conducted record review and obtained the following documents: Nurse notes (June 2023), doctors notes (June 2023), Physicians order for medication, Medication administrative record (MAR), Physicians report, Do not Attempt Resuscitation (DNR) order, and Individualized health care plan (IHCP).

LPA conducted interviews with 3 staff at 10:33 AM. Both S1 and S2 stated that C1 was given her medication for muscle spasms; S1 mentioned at 6:45pm C1’s medication was given. Staff follows physician’s order for medication. S1 informed LPA that C1 was doing fine and there were no concerns. S1 evaluated client after C1 was spastic; C1’s spasms were not bad during the time. S1 and S3 stated C1 has spasms every day. S2 stated that C1 became spastic after a few bites of her food, then S2 left C1 unattended to take C1’s food tray to the kitchen to allow client to relax so staff can feed her later. C1 does not need one on one care. S1 stated that S2 stopped feeling C1 and left C1 unsupervised for less than a minute to put C1’s food tray away so staff can feed her later. S1 told S2 to turn on C1’s fan. S2 went into C1’s room and found C1 unresponsive. S1 called 911 at 8:25PM on 6/20/2023 and was advised by 911 dispatch to perform CPR on C1. C1 has a Do not Attempt Resuscitation (DNR) order on file.

LPA will return at a later time if necessary.Exit interview conducted with ADM and copy of this report provided.