Violation Details: 00131654-AP-103003

Date
3/25/2021
Report number
00131654-AP-103003
Type
Abuse: Neglect
Level
4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation
Failed to provide safe environment
Result
Substantiated
Findings
On or about March 25, 2021, Alleged Victim (AV) suffered an unwitnessed fall, was taken to the hospital for treatment, and was diagnosed with a fractured left radius head. AV's is care planned to use a walker during ambulation and at time of fall AV's walker was not next to him/her. An investigation determined that staff were not familiar with the intervention to remind and assist AV with his/her walker, staff were not aware of AV being a fall risk, and staff were not documenting AV's refusals to use his/her walker. At time of incident, the facility was short staffed with one staff providing care for fourteen (14) residents. The facility failed to provide a safe environment for AV which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP21-02765 $1500.00 fine assessed