Incident investigation·June 6, 2023

06/06/02023 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with licensee Linda O’Sullivan. Today’s visit is regarding an incident that occurred on 05/30/2023 and was reported to licensing on 05/30/2023. It was reported that on 5/30/2023 Resident 1 (R1) was found on the floor of their room with their right leg twisted sideways. Staff called 911 and R1 was transported to the ER, x-rays were performed and R1 was diagnosed with a small fracture of the upper arm. R1’s arm was placed in a sling and R1 returned home to the facility. On 6/05/2023 a second incident report was submitted reporting that 911 was called and R1 had been transported to the hospital on 6/03/23 due to continued pain that was not being managed by pain medication. The facility reported that R1 was showing further decline. R1 was hospitalized for 24-hour observation. Facility was notified by R1’s family that R1 has passed away at the hospital on 06/04/2023. During the course of the investigation, it was learned that staff had just checked on R1 directly before R1 fell and observed R1 to be in their bed at that time. Staff walked out of R1's room and immediately after they left the room they heard R1 fall. R1 stated they reached for a blanket on a chair and fell. The facility had planned to open R1 to hospice services when they returned to the facility but R1 passed away at the hospital during the subsequent hospitalization where they were admitted for observation. No deficiencies were cited as a result of today’s visit.