Violation Details: 00105322-AP-080391

Records Request Print
Date
9/28/2020
Report number
00105322-AP-080391
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
On or about September 28, 2020, the Alleged Victim (AV) fell from his/her wheelchair and hit his/her head on the floor causing a laceration to his/her head. It was recommended to the facility for the staff to use a gait belt and/or use three staff to transfer AV or to move to and upright position in his/her wheelchair. The care plan was not updated to reflect this information and staff were not aware. When AV's wheelchair was moved and AV fell, he/she was slumped to the side in the wheelchair and should have been moved upright before the chair was moved. The inaction by the facility to properly care plan for AV caused AV to fall and receive an injury. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP21-01777 $225.00 fine assessed