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25 | Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Cinthya Gamino.
LPA is following up regarding a recent incident involving resident, R1 who had a fall that resulted in a fracture. Resident had an event where they slid down the couch onto their side. Per chart notes and staff interview, R1 did not complain of pain at that point and slept through the night. The following morning, R1 complained of pain so was sent to the hospital where they were diagnosed with a fracture. R1 was not identified as needing 1:1 supervision.
During inspection, LPA learned about another incident where resident, R2 had a fall that was un-witnessed. Once found, staff assessed resident and sent them to the hospital. Per Administrator, they were given conflicting reports about whether resident was diagnosed with a fracture. Resident was eventually admitted to a skilled nursing facility where they passed away approximately two weeks later. R1 was not identified as needing 1:1 supervision.
No deficiencies cited during this inspection. |