- Date
- 2/18/2020
- Report number
- 00073235-AP-053687
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is a known fall risk and experienced seven falls the first two weeks he/she was at the facility. Four of the seven required treatment at the emergency room. On or about February 18, 2020, AV rolled out of bed and fractured his/her L3. On or about February 27, 2020, AV rolled out of bed twice and was seen at the emergency room for both falls. AV's emergency pull cord was not accessible to AV. Interventions outlined in the service plan were vague and did not clearly defined leaving staff to interpret what they needed to do. Interventions failed to take into account that six out of seven falls occurred from AV rolling out of bed. The facility failed to care plan and implement appropriate interventions to mitigate AV's risk of injury due to falls, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP20-01052 $1500.00 fine assessed