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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Margarita Guerrero, Business Office Director, explaining the purpose of today's inspection. LPA was informed there is an Interim Administrator at this time.
LPA discussed an incident report submitted to the Department on 1/9/24 for an incident occurring on 1/5/24 for resident (R1). The incident report notes that (R1) had an unwitnessed fall in her room at approximately 10:00 am, complained of pain on her right shoulder and back and was immediately sent to the emergency room. (R1's) family member and primary care physician were promptly notified. (R1) was admitted to the hospital due to a fractured rib and will transfer to skilled nursing facility prior to returning to the community.
The BOD indicated that just prior to falling on 1/5/24, (R1) had returned (2) days earlier from the hospital with a diagnosis of pneumonia and had begun taking antibiotics. File review confirms an updated physician's report was obtained on 12/31/23 and (R1) was treated for pneumonia. Additionally, the report notes (R1) is hard of hearing, can be confused but is able to follow directions and communicate. BOD indicated that (R1) was not a fall risk, liked to be independent, typically did not ask for assistance with ambulating inside her room, and is very alert and oriented to time/place.
LPA reviewed (R1's) file and obtained a copy of the most current care plan dated 1/3/24. The care plan notes resident is independent with mobility/ambulation and only uses a cane to assist, does not require assistance with escorting, uses a pendant to request staff assistance, and has hearing impairment and anxiety, and receives caregiver checks 3 times daily, prior to each meal, for extra reminders.
It appears the facility acted timely and appropriately in sending resident out for a further medication evaluation following the fall on 1/5/24. BOD stated that (R1) will be reassessed and an updated physician's report will be obtained prior to (R1) returning to the community. Also discussed were any Covid cases.
There are no deficiencies issued in this report. Exit interview with BOD and copy of today's report provided. |