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32 | It was reported that the facility failed to provide supervision to resident resulting in a resident sustaining a fall causing resident to sustain significant injury and hospitalization.
During the investigation process witness statements and facility records reported the resident had been living on the Assisted Living wing and had sustained un-witnessed falls on 09/20/2023 and 10/13/2023. The facility proactively moved resident to the Memory Care wing on 10/20/2023 to provide increased supervision. Medical records corroborated the resident was moved to the Memory Care wing for “enhanced nursing support and a safer environment due to vision loss.” Although the resident was moved to Memory Care, as a preventative fall measure, the resident’s Service Care Plan indicated that the resident had been last assessed a “low” fall risk on 5-3-23 and had not been updated in accordance with the facilities Fall Risk Assessment policy. At the time, the Memory Care wing housed seven residents. Memory Care was staffed with two Resident Assistants (RA) during day shift and one RA at night.
The resident’s hospitalist was interviewed and stated the fall on 10/29/2023 most likely caused the subdural hematoma that was discovered on 11/17/2023 when the resident was sent back to the hospital with increased confusion. However, the physician also stated that it is not uncommon for a brain bleed to not show on initial CT scans after an acute injury and
normal protocol would be to conduct a 24-hr follow-up CT scan before discharging the patient, which was not done in the resident’s case, therefore her physician could not be certain when the injury occurred.
Medical records document the resident was seen by her primary care physician (PCP) on 11/09/2023, as a follow-up to the fall. The resident’s family reported the resident was still having nighttime delusions of people attacking her, but had improved in severity since the initial onset “that led to her fall out of bed.” the family declined to have a temporal arterial
biopsy conducted, as they did not want invasive testing. The resident did not show signs of cardiac compromise or acute distress. The residents PCP offered weekly follow-ups, but family requested bi-weekly follow-ups.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNBUSTANTIATED.
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