Facility Evaluation Report

10/24/2023 9:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with house manager Cathryn Russell . Today’s visit is regarding an incident that occurred on 09/20/2023 and was reported to licensing on the same day.

It was reported that on 09/20/2023 at 1:00 PM Client 1 (C1) was finishing eating lunch at the dining room table when staff noticed they started to slump over, leaning, almost falling out of their chair. Staff checked C1’s blood pressure and it was 57/43. C1 started becoming non-responsive to staff. 911 was called and C1 was transported to hospital.

During the course of the investigation, it was learned that C1 is high functioning but non-verbal and communicates with their hands. C1 usually has high blood pressure but it is known to drop. The facility checks C1’s blood pressure at every meal. C1 also has a seizure disorder. C1 has a DNR per conservator.

In order to prevent this from happening again the facility will continue to monitor C1’s blood pressure and will ensure C1 stays hydrated. When C1 has low blood pressure staff will continue to monitor it every 15 minutes until it normalizes.

No deficiencies were cited as a result of today’s visit.