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32 | Record review of the facility daily notes revealed on 01/07/2019, R1 experienced an unwitnessed fall and no injuries were noted. On 02/12/2019, R1 fell and was subsequently taken by ambulance to the hospital. The hospital's emergency department (ED) records dated 02/12/2019 revealed R1 was brought in by ambulance after a fall at home due to R1 picking up an orange peel, lost balance, and fell. ED records revealed R1 sustained a contusion to the right orbit. On 06/06/2019, R1 fell and hit their head, and was taken to the hospital. Hospital ED records dated 06/06/2019 revealed R1 slipped on the bed and hit their head on the floor. ED records revealed R1 was diagnosed with right lateral frontal scalp hematoma swelling. On 06/10/2019, R1 fell and facility notes read “R1 falling by bed and nightstand – was not hurt”. On 06/11/2019, facility notes read “last night R1 slipped off bed, R1 don’t want anybody to know”. On 07/26/2020, R1 fell and was transported by ambulance to Riverside University Health System sustaining a cervical fracture.
Interviews with facility staff revealed R1 would often refuse any assistance, despite having poor balance and prone to falls, and would attempt to do tasks by themselves without requesting assistance. As R1's health declined and R1 had multiple falls, the facility worked with R1's family to formulate a verbal care plan to ensure facility staff were providing as much care and supervision as possible for R1. The formulated care plan included: staff checking on R1 every 2 hours, switching R1's bed to a hospital bed with bed rails per Physician Orders, and encouraging staff to walk beside R1 when they ambulated. Interview with R1’s responsible party (RP) on 09/17/2020 revealed they were notified of R1’s falls and RP worked with the facility to discuss plans to address safety concerns after each fall. RP stated bedrails were placed on R1’s bed and was informed staff will check on R1 more often. Interview with Staff One (S1) revealed staff always had to watch over R1 but after R1 returned from the hospital from their last fall in July 2020 they were informed to check on R1 every two hours and to watch R1 closely. S1 stated R1 received the hospital bed with the bed rails around August 2020 or September 2020. Interviews with staff revealed they were aware of the verbal care plan and implemented staff checks on R1 every two hours, offered more assistance to R1, and monitored R1 as they moved around at the facility. Staff were aware that R1 needed a hospital bed with bedrails.
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