Facility Evaluation Report

Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced to the facility to follow up with two significant spikes in significant incidents (Some 16+ incident reports were submitted on 3/23-3/24, variations on confusion, unresponsive, unwitnessed fall, requiring send out) that occurred in proximity to infectious control events. LPA met with administrator/executive director jackie hernandez to explain the purpose of the visit

LPA reviewed the infection control plan, with the administrator, Licensing was alerted to the outbreaks on 2/9 and 3/24 within three days to the facility noticing the coocuring symptoms. A licensed healthcare professional was consulted regarding the similar symptoms and the facility was logging the increased infection control measures(masks for staff/clients, sanitizing surfaces, letting guests know and sanitize prior to entry to the unit) to the current date. The facility reports 4 deaths during march. the facility stopped increased infection control measures after two weeks.

Per 3 facility staff on shift (3) that were available for an interview, they are generally knowledgeable about the extra infection control measures.

On a potentially related matter, LPA was informed of a clients infection that was septic during the past month, the facility provided the information that the client was out of the facility(Dec 30th(complaint of stroke) and at some point transfered to a SNF, and after coming to the facility after this period was immedately sent out to the hospital, staying at the facility for roughly the span of a day. Discharge paperwork related to the SNF visit and the Er visit after have already been submitted to the department for review.

No citations were given as part of this visit, the LPA had no further questions about the spikes in incident reporting at this time. A copy of the report was read and given to the Administrator, exit interview was conducted.