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32 | The Department conducted a facility records review and interviewed facility staff who expressed that R1 was constantly checked on every hour and, after R1 fell on March 1, 2020, R1 was put on 30-minute checks by staff. On March 2, 2020, prior to the fall and hospitalization, R1 was in their room with their spouse, had just been checked on by staff 10-15 minutes prior, was completely alert and did not exhibit any symptoms that would have indicated any fall risk. Then, on March 2, 2020 at about 10:25 a.m., R1 had an unwitnessed fall and, after being alerted be R1’s spouse, was found by staff on the floor of the bedroom bleeding from their head. R1 expressed that they had lost their balance, fell and hit their head. R1 appeared confused and disoriented, and also had a bump on their head. After R1 fell, staff had immediately responded to their room and called 911 to transport R1 to the hospital. Also, within the two (2) month period after admission, R1 had one fall and required occasional safety checks at the facility, per the care plan. A safety check log revealed that staff conducted safety checks in R1’s room at least once every hour prior to and until R1’s fall on March 2, 2020. R1 was not a fall risk prior to these incidents, and staff also followed R1’s care plan and properly responded to R1’s falls. The administrator expressed that R1 had lived at the facility for several months and, during this time, had a minor fall with no injuries, had been hospitalized once when R1 was not feeling well and a second hospitalization after the fall on March 2, 2020. After the latter fall, R1 was placed on 30-minute checks which were documented on a sheet inside of R1’s room.
A review of medical records dated March 2, 2020 to March 4, 2020 revealed that R1 was admitted to the hospital on March 2, 2020 with a small right parietal superficial laceration. A computerized tomography scan of R1’s head was negative and cervical spine was negative for fractures. There was also no evidence of acute intracranial hemorrhage, extra-axial collection, midline shift, herniation or hydrocephalus. A review of facility records revealed that R1 was admitted to the facility on December 23, 2019 with a diagnosis of hypertension and with the ability to ambulate independently with a walker. Facility records review also revealed that medication technicians had recently received a medication management in-service training. Also, the Department’s interviews with staff and facility records review, including an audit of R1's medication record, revealed that staff had administered R1’s medications according to physician’s orders.
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