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25 | Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced case management visit due to an incident reported to CCLD on 11/21/2022. LPA met with the Administrator for Assisted Living, Liyon O'Quinn (A1) and explained the purpose of the visit. The incident report stated that on 11/20/22 at 7:30am, Resident #1 (R1) fell in her room and was found by a nursing staff in her room sitting on the floor next to her bed. Staff noted left knee swollen and complained of pain, skin tear on right upper arm, swelling on right hand and with discoloration around right eye. Nursing staff called paramedics and R1 was admitted to the Hospital for fracture on left knee and right wrist.
Per the Administrator (A1), R1 is an independent resident who is able to ambulate on her own and does not require any assistance with mobility. R1 has a 1:1 caregiver who assists her during the day. There is a phone or life alert pendant/wrist that can be used to contact nursing staff if there is an emergency. And the nurse staff tend to the calls immediately. A1 stated that R1 has been released from the Hospital and currently in their Skilled Nursing Facility recuperating. A1 and staff will assess R1 before they release her from SNF.
LPA spoke to the Director of Health Services, Emyrose Lacuesta (Staff #1/S1) who submitted the incident report and stated that a charge nurse found R1 on the floor next to her bed during the morning rounds. S1 stated that when the charge nurse opened R1's door for morning rounds and medications, she found R-1 in the sitting position beside her bed. S1 indicated that R1 is not a fall risk and she goes to the bathroom and walks on her own. S1 stated that R1 has a PHB alert/life alert that she can use for emergency. The life alert goes straight to the nurse’s pager who is in charge during that time. S1 indicated that R1 has a 1:1 care who comes daily and assist R1 during the day.
LPA spoke to R1 with the help of her 1:1 caregiver for translation. R1 stated that she got up to go to the bathroom and lost her balance and fell. R1 cannot remember where she hit her body and right eye. R1 stated that she got help from the staff immediately and did not use the life alert because the charge nurse found her right away. R1 stated that she is feeling better now and taking pain medications. LPA observed that R1 has a soft cast with a sling on her right arm and a brace on her left knee.
Based on the physician's report, R1 had an accidental ground level fall with a history of cognitive impairment. Physician also noted that R1 is alert in bed and no acute distress. Physician will work with R1's family regarding recommendations and operative intervention.
Based on the information gathered, there are no signs of neglect or lack of supervision found. No deficiency was issued. An exit interview was held, and a copy of this report was provided to the Administrator, Liyon O'Quinn. |