Incident investigation·March 1, 2023

On 3-1-23 at 10:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding incidents which occurred on 12-8-22 and 12-28-22. LPA met with associate executive director Nicole Bacon and explained the purpose of the visit. LPA reviewed incident reports, and reviewed facility file documentation for resident1 (R1), R2, and R3. LPA also reviewed facility staffing schedule and actual hours worked for 12-8-22 and 12-28-22. Additionally, LPA conducted interview with staff1 (S1). On 12-8-22, facility reported that resident1 (R1) was found in room on the floor next to bed. According to incident report, R1 tripped over chair causing the fall and landing next to R1’s bed. Incident report further stated R1 denied hitting head but did complain of right hip pain. Facility called 9-1-1 and R1 was taken to local hospital. Additionally, facility notified R1’s responsible party and Physician within regulatory time frames. After R1’s admission to hospital, it was determined R1 sustained a right hip fracture. R1 did not return to facility. Based on interviews conducted, R1 did not push call pendant for assistance.. Based on records reviewed, R1 has care plan in place which includes fall prevention and orientation to call button. Additionally. R1 was placed on alert charting and increased supervision per facility protocol due to history of falls noted with care plan updated. On 12-8-22, facility reported that R2 was found laying on R2’s back in kitchen area of R2’s room. According to incident report and based on interview, facility staff called 9-1-1 and R2 was transported to local hospital. Additionally, R2’s responsible party and Physician were notified of incident within regulatory time frames. Based on interview, R2 did not push call pendent for assistance. Based on record review, it was determined R2 suffered a stroke prior to fall. R2 was placed on hospice upon returning as well as facility’s alert charting protocol, and is no longer residing at facility. Alert charting also included increased supervision and fall precautions in place due to history of fall with updated care plan. On 12-28-22, facility reported that R3 was found on the ground in R3’s room with head injury. Based on interview, R3 was wearing call pendant, but did utilize it prior to fall. R3 was hospitalized with a rib fracture and pneumonia. Based on R3’s history of fall, R3 had been placed on facility’s alert charting resulting in increased supervision and fall precautions in place with updated care plan. Based on interview and record review, R3’s responsible party and physician were notified within regulatory time frames. Based on interview, R3 is no longer residing in facility. Based on record review, facility utilizes a fall precaution protocol for residents with history of falls. Additionally, LPA tested call pendant system which is functioning properly alerting facility staff to residents’ name and current location as necessary for needed assistance. LPA also reviewed facility staff schedule and actual hours worked with S1. Based on interview and record review, it was determined that actual hours worked were consistent with the established facility schedule in place during the dates of 12-8-22 and 12-28-22 As a result, of today’s case management, no deficiencies cited. An exit interview was conducted with Nicole Bacon and a copy of this report was left with Nicole .