Incident investigation·July 13, 2023

07/13/2023 11:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Administrator Audra Audino. Today’s visit is regarding an incident that occurred on 07/10/2023 and was reported to licensing on 07/11/2023. It was reported that on 7/10/2023 Resident 1 (R1) was found sitting on the floor of their room in front of their recliner. Staff 1 (S1) called Staff 2 (S2) and they helped R1 up and checked R1 for injuries. S2 evaluated R1, R1 had no complaints of pain and no obvious injuries or bruising R1’s family was notified. On 07/11/2023 R1 seemed to be OK but sleepy. At 9:30 AM Home health came in and evaluated R1. R1 stood to transfer several times with no complaint of pain. At 2:00 PM R1 complained of pain to their groin and would not put weight on their right foot/leg. R1 was immediately transported to ER for evaluation, x-rays were performed and a fracture of R1’s right hip was discovered. R1 was subsequently admitted to the hospital. During the course of the investigation, it was learned that R1 had just moved into the facility on 7/10/2023 and was doing fine. R1 had previously been hospitalized and subsequently been in skilled nursing before moving into the facility. R1 was discharged from the hospital with home health and physical therapy following. Home health examined R1 on 07/11/2023 for symptoms of stroke, nurse did not mention any injuries. Prior to R1's fall staff had been checking on them every 5 minutes as R1 preferred to be in their bedroom instead of the common area. Staff followed required fall protocol and once R1 complained of pain they were transported to the hospital. R1 is still hospitalized, surgery was performed on 7/12/2023 and R1 should be discharged in about 2 days barring any complications. No deficiencies were cited as a result of today’s visit.