Facility Evaluation Report

Licensing Program Analyst (LPA) Bains arrived at the facility unannounced on 02/02/2023 to conduct a case management visit at the facility. LPA met with facility Administrator Adam Hill and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask. LPA was screened by facility staff upon entry.

LPA Bains came to facility to conduct a case management visit due an incident that occurred at the facility for R1 for 06/06/2022. On 06/08/2022, the facility submitted an incident report to the Department indicating R1 sustained a fall incident at the facility on 06/06/2022 which resulted in R1s death at hospital on the same day. A review of additional incident reports submitted by the facility to the Department for R1 indicated R1 sustained falls on 05/0722, 05/26/22, 05/28/22 and 06/03/22.

The Department investigated the incident and concluded that the fall R1 sustained on 06/06/2022 contributed to R1’s death. R1’s certificate of Death identifies “Cause of Death” as Acute Subdural Hematoma with Shift, Mechanical Fall, Acute Respiratory Failure, and Acute Cardiac Arrest; and states R1 suffered an unwitnessed, ground level fall.

Medical reports indicated R1 underwent a Computerized Tomography (CT) Scan upon admittance to the hospital which showed R1 suffered a Holohemispheric Subdural Hemorrhage, a fatal injury, because of an unwitnessed fall that occurred at the facility on 6/6/2022.