Facility Evaluation Report

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Case Management visit to conclude an incident investigation. LPA met with Memory Program Coordinator, Aiyana Martinez.

On September 24, 2024, the Department received an Unusual Incident Report from the facility regarding an incident involving Resident #1 (R1). According to the facility's report, R1 sustained a fall on September 21, 2024, and a facility nurse assessed R1 and observed grimacing and a lack of movement on the left side of their body. The nurse recommended an evaluation by emergency services; however, both R1 and their responsible party declined and R1 was not treated by medical professionals. As a result, the Department opened an investigation into the delayed medical care of R1.

A review of R1’s Physician’s Report, dated July 31, 2024, indicated a diagnosis of Major Neurocognitive Disorder (MND) and stated that R1 required assistance with bathing. The report also noted that while R1 could communicate their needs, they experienced a loss of intellectual function, including difficulty making decisions. A review of R1’s Assessment/Service Plan, dated September 3, 2024, indicated that R1 required assistance with bathing, dressing, grooming, and escort assistance while walking to meals and facility-planned activities.

A review of R1’s facility records reflected that R1 had a fall on July 28, 2024, and complained of wrist pain. R1 was taken to the hospital by their responsible party and was advised to return for a cast once the swelling subsided. Further record review indicated that R1 fell again on July 29, 2024. Facility staff called 9-1-1, and R1 was transported to the hospital, where they were diagnosed with a hematoma on the back of their head. Additionally, on July 31, 2024, R1 self-reported increased pain in their left arm, prompting facility staff to call 9-1-1 for transport to the hospital for further evaluation. Continued on an LIC 809C.