- Date
- 3/27/2023
- Report number
- 00254293-AP-209879
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) has a history of behaviors and sustaining injuries while using his/her motorized chair. AV’s behavioral plan states to offer to help AV into their motorized chair and spend one-on-one time with AV when he/she becomes agitated. According to an investigation, on or about May 27, 2023, AV was found in his/her motorized chair with a fractured leg and their room in disarray. According to documentation and witnesses, approximately twenty to thirty minutes prior to the incident, the AV was placed into his/her motorized chair and left alone in his/her room as a re-directive method due to continued behaviors. It was also discovered that facility staff has used this re-directive method on several occasions. The facility failed to provide oversight to ensure facility staff followed AV’s behavioral support plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP23-01259 $500.00 fine assessed