Incident investigation·May 18, 2021

Licensing Program Analyst (LPA) Konnor Leitzell conducted an unannounced virtual case management visit with Health and Wellness Director (HWD) Kylie Whitaker. Case management was conducted via tele-phone to discuss an incident report submitted to Community Care Licensing (CCL) on 5/17/2021. Incident report is regarding Resident sustaining a fracture from an un-witnessed fall on 5/14/2021. An interview was conducted with HWD to better understand the time frame of the incident. Through the interview conducted with HWD Kylie Whitaker, LPA discovered facility staff conducts their schedule checks, referred to as “rounds”, between the hours of 2a.m. and 3a.m.; and again between 5a.m.-6a.m. LPA was informed rounds were conducted as normal, and during second round conducted caregiver heard Resident call out for help (roughly 5:30a.m.). Upon entering Resident’s room, caregiver witnessed resident on the floor in their restroom. Through reviewing the Incident Report submitted LPA discovered facility immediately dialed 911; contacted Resident’s responsible party; and primary physician. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report is being provided via email to Health and Wellness Director Kylie Whitaker. HWD is to sign and return one copy of report via email to LPA Leitzell, and keep one copy on file.