Incident investigation·October 21, 2024

On 10/21/2024 at 2:23PM, Licensing Program Analyst (LPA) T.Syess-Gibson arrived unannounced to conduct a case management visit regarding an incident report received on 10/16/2024. LPA met with Health and Wellness Director, Kuldip Singh and Davina Barker, Regional Executive Director. Incident report dated 10/16/2024 revealed that Resident 1 (R1) had an unwitnessed fall resulting in laceration to head and a fractured pelvic. LPA interviewed Staff one (S1) who stated Staff two (S2) contacted (S1) after responding (R1) pendant call at 10:30AM. LPA was not able to interview Resident 1 (R1) at the time of visit , resident is at skilled nursing facility due to pelvic fracture. LPA was not able to interview Staff two (S2) who was off of work during visit. Interview with Staff 1 (S1) revealed that resident (R1) informed both staff members of walking with walker out of the restroom in her apartment when she suddenly lost her balance and fell. (R1) hit her head on the cabinet resulting in head laceration. (S2) applied pressure on head laceration, stopping the bleeding before paramedics arrived. R1 was transported to the hospital by paramedics. S1 also stated (R1) isn't a fall risk and hasn't had any other incidents pertaining to falls. LPA collected the following documents: Incident report(s) for October 2024 and Resident roster, No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to Davina Barker