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32 | Resident is not being assessed for injuries after fall:
Facility staff left resident on the floor after calling 911:
On 10/01/2025, LPA interviewed Director of Health Service (DHS) Rosalie Hulog and Memory Care Manager. Both stated the facility policy is that caregivers are not allowed to move residents when they find residents were on the floor. The caregivers need to call nurses first (if nurse is busy, caregivers need to call Med Tech to come). Both stated the nurses check/evaluate resident on the floor and call 911 immediately. Both stated nurses check resident visually only. Both stated nurses cannot move the residents on the floor until paramedics come on site to evaluate the residents. Both stated nurses check if resident on the floor painful, bleeding, and check the vital signs. Both stated the nurses need to prepare the resident's document and to answer the questions from paramedics to help residents to be sent to hospitals. Both stated the policy was instructed to staff during the staff training.
ON 10/01/2025, LPA interviewed the facility staff LVN (S1). S1 stated on 9/22/2025, he/she was notified by a caregiver that memory care unit resident R1 was found on the floor in R1's bedroom. S1 stated he/she went on site of R1's bedroom. S1 stated he/she called 911, evaluated R1 and prepared R1's document to be sent to hospital. S1 stated the facility's policy is not to move residents who are found on the floor. S1 stated another caregiver S2 was with him/her on site to take care and monitor R1.
LPA interviewed caregiver S2. S2 stated he/she was notified on the floor in R1's room by another caregiver. S2 stated when he/she was on site at R1's room, S1 already there. S2 stated he/she observed S1 assessed R1 and prepared R1's document for the emergency room. S2 stated R1 stated he/she was fine but legs were numbed. S2 stated the facility policy is not to move residents who are found on the floor.
Based on the review of the incident report dated 9/2325, R1's vital signs were 120/57 for blood pressure, 98.2 for temperature, 80 for pulse, 18 for respiratory rate, and 98% for oxygen.
Based on the review of the facility policy of fall, it specifies do not move or lift an individual off the ground until it's verbalized that there's no pain and able to get up with minimum support and able to bear weight and ambulate.
Continue on LIC9099-C. Page 2 of 3. |