- Date
- 11/13/2022
- Report number
- 00231732-AP-189553
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The facility failed to properly train staff on how to lift a resident who is care planned as a two person assist by hoyer lift. Based on facility documentation, the facility's lift policy includes staff training to be provided by a medical professional. An investigation determined that Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) were not properly trained by a medical professional prior to assisting Alleged Victim (AV) with a transfer by hoyer lift which resulted in AV falling out of his/her Hoyer sling, hitting his/her head on the hoyer lift base causing a head injury, and being sent to the hospital for treatment. The facility's failure to provide a safe environment for AV resulted in pain and unreasonable discomfort to the AV which is a violation of resident rights, is considered neglect of care and constitutes abuse. AP2 and AP3 allegedly neglected AV when AP2 and AP3 failed to provide a safe environment for AV during a transfer by hoyer lift. An investigation determined no abuse occurred by AP2 and AP3.
- Sanction
- RCFCP23-00635 $1500.00 fine assessed