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32 | According to the Physicians Report dated June 3, 2019, R1’s diagnosis included dementia and was unable to make their needs known. Facility records including the Level of Care Assessment completed on February 19, 2020, and incident reports of falls on February 4, 2020, February 14, 2020, and March 6, 2020, document that R1 was a fall risk and had a history of falls. Interviews with the Facility Administrator, staff, and other witnesses confirmed they were aware of R1 being a fall risk and had a history of falls. R1’s care plan dated February 19, 2020, also identifies R1 as having mild to severe Aphasia and unable to communicate. R1’s care plan identified the need for assistance with activities of ambulating, dressing, hygiene as well as shower assist. In addition, the care plan documented R1’s preference of afternoon showers. On the morning of May 7, 2020, records and interviews stated that R1 was agitated. The investigation concluded that facility staff (S1, S2) were giving R1 a shower on May 7, 2020, at 6:25 A.M. R1 was seated on a shower chair at the time. S1 was directly assisting R1 in the shower area and S2 had stepped away from the bathroom area to gather supplies. S1 then stepped away from R1 momentarily to get shampoo at which time R1 fell off the shower chair and onto the floor, sustaining injuries. R1 was taken to the hospital on May 7, 2020 and was diagnosed with an accidental fall; C1 and C2 cervical fracture, forehead abrasion and traumatic hematoma of the forehead.
R1 remained in the hospital from May 7, 2020 and passed away on May 11, 2020. The Department obtained and reviewed R1’s medical records and death certificate. According to hospital documentation, neurosurgery recommended against any surgical intervention, and recommended a hard collar for life. However, R1 was unable to speak or swallow, known as dysphagia. According to the National Institute on Health, non-operatively managed patients with C1 fractures are 4 times more likely to have dysphagia. On May 8, 2020, a swallow evaluation was performed by a Speech Pathologist, who attempted a by mouth trial of ice chips. R1 made no attempt to orally manipulate the ice chip in their mouth. The Speech Pathologist recommended nothing by mouth due to the lack of R1’s swallowing reflex. According to the physician’s notes, R1 was identified as having a poor prognosis. According to the Death Report Summary obtained from the acute hospital, R1’s family agreed to comfort care and hospice and R1 was started on low-dose maintenance of morphine. Over the next few days, R1 was unable to eat or drink. On May 11, 2020, at 2:16 A.M., R1 passed at the hospital. The cause of death on the death certificate was listed as cardiopulmonary arrest, cervical spine (neck) fractures and ground level fall. John Hopkins University describes cardiopulmonary arrest as when the heart suddenly stops beating. |