Incident investigation·October 10, 2023

10/10/ 2023 1:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Sue Todd. Today’s visit is regarding an incident that occurred on 10/08/2023 and was reported to licensing on 10/10/2023. It was reported that on 10/08/2023 at 5:24 PM Resident 1 (R1) was getting up from a table in the dining room and they lost their balance, fell backwards and hit the back of their head on a table. R1 did not lose consciousness and was awake and responding. R1 sustained a laceration to their right elbow. R1 was transported to ER for evaluation and subsequently admitted for acute hyponatremia, acute ground level fall with head strike and elbow contusion. During the course of the investigation, it was learned that R1 was hospitalized for low sodium level, not related to R1’s head strike. R1 is currently still at the hospital where they are working on getting R1’s sodium regulated. In order to prevent this from happening again the facility has requested home health to come in to ensure R1 has no further issues. Facility is going to request physical therapy for R1 due to a recent issue with getting up and down from a seated position. No deficiencies were cited as a result of today’s visit.