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32 | floor in a common area. Staff assessed R1 and determined their vitals were within normal range. Staff noted a raised bump on the back upper left side of R1’s head. R1 complained of pain. 911 was activated and R1 was transported to the hospital for medical care.
Medical records showed R1 arrived at a local hospital emergency department by ambulance on
9/9/2020 at 9:26 PM with the chief complaint: “Fall.” Records indicated R1’s visit diagnoses were Subdural hematoma (primary); bleeding in brain; contusion of scalp without laceration and Alzheimer’s dementia without behavioral disturbance. R1 was transferred to another hospital on 9/10/2020 to provide R1’s responsible person time to decide the level of care and intervention needed for R1. R1’s responsible person declined surgery for R1 and directed that R1 return to the facility under hospice care. R1 passed away at the facility on 9/16/2020.
R1’s Certificate of Death documented the immediate cause of death as “Blunt Force Injury of Head.”
Other significant conditions contributing to R1’s death but not noted as the underlying cause were “Dementia and Hypertensive Cardiovascular Disease.” Records and interviews did not provide evidence to indicate that the facility could have prevented R1’s fall or provided neglectful care.
An outside source also alleged that the facility failed to ensure adequate staffing to meet resident’s needs. Interviews of the staff working on the night of R1’s fall were completed as part of this investigation. On the evening of R1’s 9/9/2020 fall, Staff 1 (S1) was in the common area with approximately 4-5 residents, including R1. S1 last noticed R1 sitting on a recliner chair in the corner of the room. S1 was assisting another resident in the front of the room when they heard a noise that sounded like something hitting the floor. S1 did not visually witness the fall but turned around and saw R1 on the floor. R1 was lying on their back next to the recliner chair. S1 called out to Staff 2 (S2) for assistance who responded. Additionally, Staff 3 (S3), a licensed vocational nurse, arrived and assessed R1. R1 was noted to have a nodule on the back of their head. 911 was activated and R1 was transported to the hospital for medical care. Interviews revealed that generally speaking, staff checked R1 and other residents at least every two hours to monitor and assist as needed for safety. Interviews also related that the facility does not provide 1-on-1 resident care.
In regard to the allegation that the facility failed to update R1’s care plan due to multiple falls, interviews and records characterized R1 as very mobile and active. Since moving into the facility, R1 experienced seven witnessed and unwitnessed falls, including the 9/9/2020 incident. None of the first six falls resulted in |