Incident investigation·August 17, 2022

On 8-17-22 at 2:15pm, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to open a case management related to incident reports dated 7-8-22, 7-9-22, and 7-11-22. LPAs met with Administrator Mary Margaret Chappell and explained the purpose of the visit. LPAs also reviewed facility file documentation including progress notes for resident1 (R1), Physician's report for R1, Personalized service plan for R1, and staffing schedule for July 2022. LPAs also interviewed Administrator and Staff1 (S1). Based on records reviews and interviews, it was determined that R1 sustained falls on the three dates noted above and sustained a head injury as a result. Based on additional record reviews and interviews, it was determined that facility had implemented fall prevention precautions for R1 and increased staff monitoring of R1 on 7-11-22 due to recent falls. R1 was place on hospice on 7-12-22 and expired on approximately 7-22-22. Staffing schedule indicates adequate staffing levels on dates of reported falls. LPAs conducted check of facility's emergency pendant system and determined that system is functioning adequately. As a result of today's case management visit, no deficiencies are issued. An exit interview was conducted with Mary Margaret Chappell and a copy of this report was provided to Mary.