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32 | Staff revealed that R1 is being monitored frequently. However, they were unable to specify why and how often they monitor R1.
S1 indicated that R1 was a fall risk resident and was falling 2-3 times a month. S1 had no knowledge if there was a fall prevention plan for R1. S1 is a Med -Tech. However, he was trying to monitor the resident every time he was passing by R1’s room. On 04/09/2023, while passing by R1’s room, S1 heard R1 calling for help and went to assist. R1 was on the floor and had bruises all over their body. S1 was not sure how long R1 was on the floor. He called 911 and R1 was send to the hospital.
A review of R1’s internal incident log for the month of April 2023, revealed that within one month R1 had four un-witnessed fall incidents; on 04/09/2023; 04/25/2023, 04/26/2023 and 04/30/2023.
A review of R1’s need and service plan does not reveal any information regarding R1 being a fall risk resident and/or identifying fall prevention assistance.
No documents were available at the facility to clarify how the facility staff is meeting R1’s un-met needs.
Based on inspection, observation, interviews and record review, there is a sufficient information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.
Under Title 22, Division 6, Chapter 8 following citation was issued and recorded on LIC9099D.
No immediate Health and safety hazard is noted during this visit.
Exit interview was conducted, appeal rights discussed and a copy of report was issued. |