Facility Evaluation Report

On 5/10/2024 Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced case management visit to the facility for incidents of unwitnessed and witnessed falls.

R1 had a witnessed fall on 5/1/2024, R1 was taken to the ER and was diagnosed with a fracture of the Tibial Plateau. R1 returned to the facility on hospice. R1 service plan dated 4/16/2024 confirmed that R1 was a two person assist with transferring. Based on the incident report dated 5/7/2024, R1 was transferring from the recliner chair to the wheelchair and fell. R1 was being assisted with transferring by S1, the facility did not have as assessed a second person to assist with the transfer and as a result R1 fell and sustained a fracture.

R2 was sent out on 4/13/2024 for evaluation from feeling sleepy and lethargic. During the review of the file the department discovered that R2 had a fall on 4/15/2024 witnessed by R2's wife and reported to the facility. R2 was sent out to the ER at St. Joseph's hospital. The discharge summary listed the chief complaint as a fall yesterday(4/15/2024) w/subdural hemorrhage. R2 was discharged and scheduled to see the primary care physician on 5/8/2024. R2 did not return to the facility after April 15th 2024. Continued