Violation Details: 00181426-AP-144258

Date
1/28/2022
Report number
00181426-AP-144258
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide safe environment
Result
Substantiated
Findings
Alleged Victim (AV) relies on the facility for a safe environment. AV has history of behavioral changes when s/he misses a dose of h/h antipsychotic medications. On or about January 22, 2022, and January 23, 2022, AV did not receive h/h antipsychotic medication due to the facility not having the medication in stock, resulting in escalated behaviors on January 23, 2022, and January 24, 2022. AV has a history of falls. On or about January 25, 2022, AV was heard yelling in pain, and found in bed with a reopened skin tear on h/h arm. PRN medications were not effective, and AV was sent to the ER, where AV was diagnosed with bruising, on h/h right elbow and a right hip fracture. The Facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
RCFCP23-00320 $1125.00 fine assessed