Incident investigation·April 21, 2023

On 4/21/2023 LPA Tryon visited the facility to do a case management visit regarding incident reports received, LPA received reports dated 4/15/2023 and 4/20/2023 regarding resident R1 having two separate falls. LPA learned that R1 was taken to the Emergency Room after each fall. ER doctor would not do a complete work-up as R1's DNR stated comfort care only, so no reason was determined for R1's falls/increased loss of balance. At this time, hospice services have been initiated for R1. This will assist to monitor his medical issues, because he will have hospice professionals coming in to provide care. The hospice agency is going to look at possible medication changes to see if that can help. R1 was not previously a fall risk and was very mobile around the community It appears that the facility has reacted appropriately by sending R1 out right away and seeking assistance; and now hospice services will be initiated.