- Date
- 10/24/2021
- Report number
- 00179286-AP-326269
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- On or about August 13, 2021, AV was documented to be a high fall risk, with one-person assist needed for gait belt transfers, toileting, and ambulation. It was noted that AV may not use h/h call light to request assistance, and that staff were to check on AV 6 times per shift. AV was to have a scoop mattress and a tab alarm when AV is in bed. Staff were to ensure the alarm is on. On October 23, 2021, staff was coming into AV’s room when they saw AV fall while trying to get out of bed by h/h self. AV sustained bruises on h/h left hand and leg. Service plan written for AV on November 13, 2021, after the fall on October 23, 2021, lists the same fall prevention interventions as noted before AV’s October 23, 2021, fall. No new interventions were implemented after the fall on October 23, 2021. On or about November 27, 2021, AV fell after leaning back and sliding down the wall, sustaining an abrasion to h/h right elbow. The only intervention noted was for staff to use a gait belt with AV. This intervention had already been put in place on the August 13, 2021, Service Plan, which was also in place on the November 13, 2021, service plan. AV fell in the bathroom on December 16, 2021, when left alone while staff stepped out for a brief. Intervention noted was for staff to bring supplies to the restroom when toileting AV. No interventions were implemented that would prevent a fall under any other circumstances even though AV had fallen twice under different circumstances on October 23, 2021, and November 27, 2021. Progress Notes from December 27, 2021, indicate AV had fallen and hit h/h head. AV is unable to tell anyone if s/he is in pain, and there is no indication that the facility used a pain assessment to determine if AV was in pain after hitting h/h head. No alert charting or follow up regarding AV hitting h/h head on December 27, 2021, was found in documentation. There is no indication that the facility monitored AV for pain or injury.
AV hitting h/h head on December 27, 2021, was found in documentation, no incident report was completed, there was no indication the facility monitored AV for pain or injury as AV is unable to tell anyone if s/he is in pain. There were no new added interventions to address AV’s falls after prior falls. The facility failed to appropriately care plan and implement new reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00079 $250.00 fine assessed