Facility Evaluation Report

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to complete a case management visit. LPA met with Administrator Malissa Acuna during today’s inspection.

During the complaint investigation, LPA discovered R1 was on hospice services. In September R1 went on a walk with activities with several other residents. During the walk R1 fell on the ground and was complaining of pain. Facility called hospice, and was told to wait for a hospice nurse to assess resident. R1 was helped up and moved back into the facility. Hospice arrived 2 to 3 hours later, and instructed staff to not send resident out for emergency services. The following day, resident was still in pain and facility sent resident out to the emergency department. R1 was diagnosed with a hip fracture and sent back to the facility on hospice services. Due to facility not calling emergency services upon R1’s injury which was not related to the expected course of the resident’s terminal illness, deficiencies are cited on 809-D.

Exit interview conducted and copy of report provided. Appeal rights given.