Incident investigation·September 13, 2024

On 09/13/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced case management visit for an incident reported. LPA met with Regional Operations Specialist, Krystal Jenkins, and the purpose of today’s visit was explained. LPA conducted a case management due to two Special Incident Reports (SIR) regarding resident falls one submitted to Community Care Licensing (CCL) on 08/30/24 and the other on 09/02/24. Resident R1 experienced a fall on 08/27/24 resulting in a right distal radius other type extraarticular fracture. Resident R2 experienced a fall on 08/28/24 resulting in a right subtrochanteric fracture requiring surgery. During today’s visit, LPA toured the facility, checked all hallways, walkways, common rooms, and resident R1 and R2’s room. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All common rooms and Resident R1 and R2’s room was observed clean, clear, and free of hazards. All rooms was observed with ample lighting. LPA reviewed resident R1’s Physician’s Report (Exam on 12/27/23), Preplacement Appraisal Information, Needs and Service Plan (updated 05/3/23), hospital discharge paperwork, Internal Incident Report and Progress Notes. LPA observed R1 has a minimal history of falls. When LPA conducted a follow-up call the Health Service Director, stated R1 does not have a fall plan. LPA reviewed resident R2’s Physician’s Report, Resident Care Assessment, MC Assessment, Progress Notes, and Internal Incident Report. When LPA conducted a follow-up call the Health Service Director, stated R2 is considered a fall risk due to their medical diagnosis. During today’s visit, LPA did not observe any Health and Safety violations. An exit interview was conducted exit interview with Regional Ops Specialist, Krystal Jenkins, and a copy of this report was provided.