Incident investigation·January 2, 2025

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA identified himself and disclosed the purpose of the visit to Executive Director Emily DeLaBarre. On 12/09/2024, the Department received an incident report indicating Resident # 1 (R1) had sustained a fall that was not witnessed, on 12/05/2024. R1 initially declined having pain, but later reported pain and was transported to the hospital. R1 was discharged with not fractures. On 12/12/2024, R1 reported excruciating pain and was transported to the hospital and diagnosed with a pelvic fracture. Review of records revealed R1 had a CT scan and several X-ray exams preformed during R1's hospital visit on 12/05/2024. These exams did not reveal any fractures and R1 was discharged back to the facility. Per interview with Executive Director DeLaBarre, R1 did not sustain any additional falls between 12/05/2024 and 12/12/2024. At this time,R1 is still at the hospital receiving treatment. Additional visits and review of additional pending records is necessary. An exit interview was conducted with Executive Director DeLaBarre, to whom a copy of this report, and Licensee/Appeal Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received.