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32 | R1 was an 88 year resident considered non- ambulatory due physical and mental state, required supervision when ambulating with a walker, required assistance with escorts, and was diagnosed with Dementia, hypertension, and general weakness among other comorbidities.
Interviews with internal sources revealed R1 resided at the facility from 4/27/23 to 5/5/23. The facility staff had conducted visual checks on R1 every two hours, or less. After the initial fall was reported, interviews consistently revealed R1 was placed on alert charting, which increased the frequency of each check to every hour and staff spent more time with R1 during each check. It was believed R1’s bed was high off the ground, not appropriate and a possibly contributed to the falls. Interviews consistently disclosed staff had notified R1’s family R1’s bed may not be appropriate, but family declined to provide a lower bed. During the second fall on 5/4/23, staff reported family and staff had interacted with R1 prior to the fall. Staff had checked on R1 approximately twenty minutes prior to the fall, and staff had witnessed R1’s family exiting the room after.
Interviews with external sources revealed R1’s family believed the facility was understaffed, because R1’s spouse, who resided with R1, was once found with a soiled undergarment. It was confirmed R1 no longer resided at the facility, and R1’s had a lower hospital bed which made it easier for R1 to ger in and out.
Although a review of records revealed R1 was considered non-ambulatory, was a fall risk, and required assistance with being supervised when ambulating with a walker, there was not enough evidence to support staff negligence resulted in R1 sustaining injuries. Both incidents were unwitnessed, staff responded and summoned medical attention, therefore, the allegation was Unsubstantiated.
It was alleged the licensee did not address resident's change in condition. Review of incident reports along with interviews confirmed R1 had two unwitnessed falls. The first fall occurred on 5/3/23, R1 was found by staff, was transported for medical attention, and returned with not injuries noted. The second fall occurred on 5/4/23, R1 was found with a facial laceration and was transported for medical attention. Interviews consistently revealed staff had conducted wellness checks on average every two hours. After the initial fall, management relayed R1 would be placed on alert requiring hourly wellness checks. Staff confirmed alert charting, hourly wellness checks, and observation was increased for R1. Although a higher bed was identified as a possible contributor to R1’s falls, and a care conference may have been scheduled to discuss appropriate level of care, there was not enough evidence to prove staff did not address R1’s change of condition. |