--00000000000016aed2063c6a0361 Content-Type: text/plain; charset="UTF-8" Content-Transfer-Encoding: quoted-printable Would the information below be sufficient, Timothy? _________________________________________I&A Report: 2025 Detailed Incident Summary In 2025, three separate incidents were documented, involving two client falls and one medication error. - *Dr. Khoday (February 12, 2025): *The client was in the kitchen when she suddenly got dizzy and fell forward onto her knees. The caregiver heard the fall from another room and came to assist. The client experienced pain in her knees and had difficulty walking afterward. - *Mme Paulette Marcotte Lafleur (July 19, 2025):* After returning from dinner, the client was settled in a chair. When the caregiver briefly went to the washroom, the client attempted to get up with her walker; th= e walker pushed forward, and she fell onto her buttocks. No immediate injuries were reported, but she was later taken to the hospital as a precaution. - *Mrs. **Carolyn Wilkinson Kott (August 2, 2025):* A medication error occurred when the evening caregiver administered an old medication. The daytime caregiver had sent a text with instructions from the pharmacist = not to take the old medication, but the evening caregiver did not see the message in time. The client did not suffer any injury from the error. ------------------------------ Root Cause Analysis The underlying causes of the 2025 incidents were varied, pointing to client health, equipment use, and internal communication processes. - *Acute Client Health Event*: Dr. Khoday's fall was directly caused by a sudden bout of dizziness, a physiological event that could not have been anticipated by the caregiver at that moment. - *Unsupervised Client Action & Equipment Misuse*: Mme Lafleur's fall was a result of her attempting to get up on her own combined with the walker moving forward. This indicates a risk associated with clients who have a known history of falls attempting to ambulate without direct supervision= , even for a moment. - *Communication Process Failure*: The medication error for Mrs. Kott was caused by a reliance on a non-secure, passive communication method (text message) for a critical, time-sensitive instruction. The failure was not in the sending of the information but in the lack of a system to confirm= it was received and understood before the medication was due. ------------------------------ Corrective Actions and Follow-up Immediate and subsequent actions were taken to address each incident. - *Immediate Care & Medical Escalation*: For Dr. Khoday, the caregiver helped her to the couch and provided Tylenol for pain. For Mme Lafleur, a Residence nurse was called immediately to check her, which led to the decision to call an ambulance. The caregiver stayed an extra three hours until the residence staff took over supervision. - *Management & Family Communication*: In all cases, the case manager was notified promptly. Management advised Dr. Khod