- Date
- 2/19/2021
- Report number
- 00126027-AP-098082
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- On or about February 19, 2021, Alleged Victim (AV) fell from a chair in the dining room suffering a laceration to his/her right hand, a dislocated shoulder, and a fracture to his/her humerus. An investigation determined that AV has a history of falls and cognitive deficits and that AV's care plan required the use of a pad alarm in AV's chair to alert staff that AV is moving around or attempting a transfer without assistance. At time of the incident, AV's pad alarm was not in the chair which AV fell from. The facility's failure to follow AV's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP21-02586 $1125.00 fine assessed