Coventry Court Health Center

Review of Resident 1's SBAR Summary for Providers dated 8/28/25, showed the resident had a fall and the physician had ordered for the resident to be transferred to the acute care hospital.

Review of Resident 1's IDT dated 8/29/25, showed Resident 1 had a fall on 8/28/25.

The note showed prior to the incident, the resident had been wheeling self independently with constant supervision by nursing staff.

The resident was last seen by the CNA and LVN by the nurse's station at around1440 hours.

The note further showed the resident continued to wheel self and constant redirection had been offered to the resident, but had not been easily redirected.

On 9/25/25 at 1315 hours, an interview and concurrent medical review was conducted with RN 2. RN 2 stated Resident 1 was a wanderer. Resident 1 would wheel himself everywhere inside the facility and sometimes from room to room.

When asked for how long Resident 1 was in the patio, RN 2 was not able to determine. RN 2 acknowledged the resident's whereabouts were not monitored. On 9/25/25 at 1430 hours, an interview and concurrent medical review was conducted with the ADON/IP.

The ADON/IP stated the resident would wheel self constantly and goes from room to room.

The facility staff would always redirect Resident 1 and the resident would stop but would then continue to wheel himself aimlessly.

When asked where did the CNA last saw Resident 1, the ADON/IP was unable to provide the information.

The ADON/IP verified Resident 1 was alone and unsupervised in the patio when the fall incident happened. On 9/25/25 at 1615 hours, the Administrator and DON was made aware and acknowledged the above findings.

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