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32 | (Cont. from LIC 9099)
The resident was found lying in the middle of the bed with water on the floor but the bed dry. Staff did not suspect a fall because the resident typically requires assistance to get out of bed and was found on the bed when checked. Staff consistently stated that they conduct routine checks every 1–2 hours overnight and use sound monitors, which function similarly to baby monitors. These devices allow staff to hear sounds coming from residents’ rooms during the night so they can respond promptly if additional assistance is needed.
Attempts were made on several occasions to interview outside sources, including R1’s Power of Attorney (POA); however, no contact was successfully established during the investigation. LPA attempted to interview R1, however due to R1’s major neurocognitive disorder they were not able to be qualified for interview.
During an unannounced facility visit, LPA observed R1’s room with clean sheets, clean floors, and free of hazards. R1 was observed asleep, clean and well-groomed. Pool noodles were observed attached to the bed rails for injury prevention while residents are sleeping. Staff explained that residents may toss and turn during the night and could hit their heads on the rails; the pool noodles are used as padding to reduce the risk of injury. This modification does not interfere with the intended purpose of the bed rails, which is to assist residents with mobility. A camera with a posted 'camera in use' notice was observed in the room, installed by R1’s POA for additional monitoring.
Review of facility records corroborated staff interviews. R1's Plan of Care, LIC 602, Needs and Services Plan, and Resident Appraisal, reflects that R1 requires one-person assistance for all ADLs and needs frequent reminders for toileting. R1 is ambulatory with assistance or walker, and has some visual impairment. Records confirm reduced mobility and frequent confusion, due to dementia. The incident report was consistent with staff statements as staff documented that they found R1 on their bed with legs hanging off the edge, pants removed, and assumed urine on the floor. The incident was unwitnessed, and it was unclear whether a fall occurred as R1 did not express pain or discomfort, and was found on the bed, not the floor. The facility consulted a physician and nursing staff following the incident. R1's diaper check logs revealed routine checks throughout the day and every two hours overnight, including the day of the incident that occurred. Records did not give evidence that R1 was not being supervised according to their care plan and routine checks during the time of incident. (Cont. on LIC 9099-C pg. 1)
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