Incident investigation·May 14, 2024

Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident. LPA reviewed special incident report dated 4/27/2024 stating R1 had an unwitnessed fall and as a result sustained a fractured hip. R1 has a history of falls and the facility has taken precautions to minimize R1 from falling. R1 has an updated service from 3/20/2024 based on the assessment R1 was independent with transferring. After the fall and ER visit on 4/27/2024, R1 was discharged to a skilled facility for rehabilitation and will be assessed to return on 5/15/2024. R1 moved in on or about 12/20/2021 without any durable medical equipment. During today's visit, LPA reviewed R1's file, medical records related to the fall and service plan which is dated 3/20/2024. Exit interview was conducted with Staff.