Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with Jhanell Edmalin (House Manager). The purpose of this case management inspection is to follow up on an incident and death report received at Community Care Licensing (CCL) dated 3/18/24.

Community Care Licensing previously received incident reports about client's (C1) hospitalization dated 3/11/24, 3/13/24 and 3/18/24 reporting C1 had an unexpected death while staying in the hospital. Per incident report, on 3/8/24 at around 9am, C1 was observed by facility staff with their tummy bloated, staff assessed C1 and decided to bring C1 to the emergency room for further evaluation. Responsible parties were notified including CCL. C1 was discharged on 3/9/24. On 3/11/24 around 10:30am facility staff noticed C1 appeared weak, their tummy was bloated and C1 reported pain. Staff immediately called their primary doctor who advised them to bring C1 back to the hospital, where they were admitted and discharged on 3/14/24 at 2:30pm with a diagnosis of hemoperitoneum. On 3/14/24 at around 9pm, staff observed that C1 was having difficulty breathing, they appeared pale and confused, so the staff decided to bring them back to the hospital, where they were admitted to perform further evaluation and testing. On 3/16/24 C1 was transfer to the ICU area due to the results indicating a diagnosis of sepsis, then they passed away same day due to septic shock after their responsible parties determined that it was the best for C1 to get disconnected from the tubes since the septic shock was not reversible.

During today's visit LPA conducted interviews with staff that revealed that C1 had a diagnosis of ovarian cancer stage 3. LPA reviewed C1's records including Physician's Report and C1's care plan dated 1/22/24. Based on records review of C1's file revealed that C1 had been seen by their Physician in a regular basis. LPA requested Death Certificate due to client not on hospice. The Department conducted an investigation into the unexpected death of client. The investigation found the facility followed all regulation and training requirements.

No deficiencies cited during today's visit.