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25 | Licensing Program Analyst (LPA), Jonathan Pineda conducted an unannounced tele-visit to conduct a case management visit regarding an unusual incident report submitted to CCL on 7/15/20. LPA identified himself and spoke with Jonetta Eads, Administrator.
It was reported that on 7/15/20, Resident 1 (R1) (Refer to LIC 811 for Confidential List of Names)
fell in their room and sustained a hip fracture. Interview and a review of R1’s Physician’s Report dated 11/19/19 and Plan of Care dated 11/22/19 revealed that R1 resides in Assisted Living and is determined to be mostly independent and able to communicate their needs. R1 requires assistance with bathing, dressing, and ambulation. On 7/13/20 at approximately 11:00pm, R1 called and requested for a Tylenol and mentioned he had fallen. R1 was assessed and facility asked R1 if he wanted to go to the hospital. R1 refused at that time. R1 was provided Tylenol as requested. Two-hour well checks were conducted throughout the night. During one of the well checks, staff asked R1 again if he wanted to go to the hospital and R1 refused again. At approximately, 10:30am on 7/14/20, R1 complained of pain. Facility staff called 911 and R1 was transported to the hospital. Interview and record review revealed that facility held an employee In-service regarding their Clinical Fall response policy to ensure 911 is always activated.
Based on interview and record review, R1 was of sound mind and able to communicate their needs. LPA did not observe any culpability. No deficiencies were cited during today’s tele-visit.
An exit interview was conducted with Jonetta Eads and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Administrator via email. An electronic email read receipt confirms the documents were received. |