Violation Details: 00141556-AP-111571

Date
5/26/2021
Report number
00141556-AP-111571
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 high risk of falls resident. Between February 23rd through May 20, 2021, AV sustained falls or had been found on the floor on approximately thirteen (13) occasions and had sustained injuries on most occasions. On or about May 26, 2021, AV was sitting in a recliner chair in the front desk area of the facility. Staff brought AV to the front desk are to have AV in their line of sight. Staff had walked away from AV, approximately five minutes later, staff heard the pressure alarm on the chair sound. AV was found on the floor bleeding from his/her head. AV was transported to the hospital and received sutures to close a laceration to his/her head. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
RCFCP22-00440 $1125.00 fine assessed