Facility Evaluation Report

On this day at around 10:30 am, LPA Luisa Fontanilla arrived unannounced to deliver findings of the investigation conducted by the Department related to a questionable death of a client while in care. LPA met with Kevin Braud and Irene Monteclar.

During the course of investigation, the Department conducted interviews and record reviews.

On 11/22/2022, LPA Leslie Ibo conducted a case management visit in connection with a self-reported questionable death of a client. On 11/28/2022, the incident was referred to and investigated by Investigations Branch (IB).

Based on records review conducted, C1's primary doctor signed off on C1's death certificate with the cause of death as Aspiration Pneumonia-Saliva Dysphagia . However, doctor believes C1's history of heart disease could have also been a factor. C1's progress notes state C1 has a history of pneumonia, dysphagia and was on a pureed diet. The doctor stated no concerns with the facility's care plan.

In regards to the suction machine used for C1, C1's doctor believes the facility already had the suction machine in the home, possibly from a previous resident, and they began to use it on C1. C1 passed away on 11/17/2022 and the facility requested an official document of approval for the usage of the suction machine on C1 on 11/22/2022. The doctor signed off on this request and approved it for it having been used previously on C1. Staff do not need training to use the suction machine if they plan on using it only in the mouth of the patient. However, if the tube goes deeper down into the trachea, then only skilled nursing staff can use it. In C1's case, the doctor believes staff were only using it in the general mouth area and they did not go further down.