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32 | The investigation revealed that on 9/15/2020, R1 was seated in their shower chair and was tended to by Staff #1 (S1) and Staff #2 (S2). While sitting in the shower chair, R1 suddenly leaned their head back and body became stiff. Witnesses claimed that R1’s eyes were wide open, teeth clenched, and R1 began to shake. It appeared that R1 was experiencing a seizure. R1’s head and shoulders were leaned back while R1’s legs and hips were locked forward. During the seizure, R1’s legs were crossed at the ankle. S1 remained with R1, and S2 went to call for help. S1 claimed they heard two loud snaps and assumed that R1 had broken one or more bones. Thereafter, R1 loss consciousness. Paramedics were called and R1 was taken to the hospital.
During the seizure, witnesses claimed R1 never fell, hit their head, or injured any part of their body. R1 was assessed and staff did not find any marks, bruising, or external injuries indicating a fall or other incidents. A review of Facility Progress Notes did not mention any falls prior to the 9/15/2020 incident. Interviews revealed that none of the facility residents nor the staff ever reported any abuse or neglect by S1 or S2.
Hospice admittance paperwork revealed that it was suspected that R1 had a seizure, as R1 had elevated lactic acid. A CT scan showed displaced left and right proximal femur fractures and an L1 compression fracture. In addition, no external marks or injuries were noted in the hospital notes. A review of R1’s facility appraisal and physician’s report revealed that R1 had a diagnosis of generalized weakness, was non-ambulatory, and required a two-person assistance for most activities of daily living. A review of R1’s Medication Administration Record (MAR) demonstrated that R1 was prescribed diazepam and gabapentin, which is prescribed to treat muscle spasms, anxiety, and seizures. In addition, R1 was prescribed glucosamine chondroitin and cholecalciferol (Vitamin D), which is commonly used to treat osteoporosis pain. According to Mayo Clinic, osteoporosis ‘causes bones to become weak and brittle – so brittle that a fall or even mild stresses such as bending, or coughing can cause a fracture’. Hospital notes revealed that R1 primarily ambulated with a wheelchair for mobilization and had not walked in years. R1’s family opted for comfort measures and non-operative care management, and R1 passed away on 9/18/2020.
Based on the investigation, evidence supports the claim that the cause of the injury is consistent with a medical issue. Hospital records note that R1 suffered a seizure and combined with R1’s immobility, osteoporosis pain and generalized weakness, it does not indicate that R1 suffered injuries as a result of physical abuse. A review of sheriff’s notes revealed that the incident was ruled a medical issue and abuse was not suspected. There is insufficient evidence to support the claim that R1 sustained fractures as a result of abuse. This allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was provided via email for signature.
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