1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on a recent incident report and hospice death reported to the facility. LPA met with Luz Jimenez, caregiver, who contacted Kim Rosa, Co-Administrator, who arrived at 3:00 pm. LPA explained reason for the inspection.
LPA discussed the incident report submitted on 11/22/23 reporting resident (R1) fell when inadvertently stepping in the shower instead of putting her bottom on the shower chair first. (R1's) feet became tangled due to her knees bowing inwards. Staff was present with (R1) during the entire incident and was able to catch her, break her fall and assist her in breaking the fall to the ground. This staff was not present to interview today. (R1) was sent out to the emergency room immediately following the fall and was diagnosed with a femur fracture. There was no head injury sustained.
Resident lived at the facility since 2017. LPA reviewed (R1's) physician's report, dated 12/19/22, which notes resident has a diagnosis of Dementia, is a fall risk and other diagnoses. Co-Administrator and staff stated (R1) had gout for many years, had foot pain, and began falling more often approximately a year ago. Staff placed a bedside commode next to the bed and (R1) began using a wheelchair more. Staff also indicated that (R1)'s appetite became less for the last (6) months. Care Plan completed in Dec 2022 by (R1's) health care plan notes resident needed some assistance with showers.
Resident returned the next day from the hospital with updated physician's report, dated 11/23/23, and under hospice care. (R1's) family opted to forego surgery due to resident's advanced age based on physician's recommendation. Staff stated (R1) returned in a lot of pain and family was at bedside for the following (3) weeks until resident passed. Hospice records show the hospice care team made (16) visits from 11/23/23 through 12/13/23. Based on information obtained, it appears the facility followed (R1's) care plan and sent resident out timely for medical evaluation following resident complaining of pain in her knee area.
There are no deficiencies issued in this report. Exit interview. Copy of report provided to Co-Administrator. |