- Date
- 8/8/2023
- Report number
- 00279375-AP-233982
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- On or about August 8, 2023, Alleged Victim (AV) fell out of his/her bed around 2 a.m. and was not found by staff until around 6:45 a.m. AV appeared disoriented and confused, showing signs of being in pain. Based on facility documentation and interviews, AV was discharged from the hospital on August 7, 2023, after having his/her toe amputated at the hospital. The facility staff developed an Individual Support Plan (ISP) noting AV's added care needs for assistance; however, AV's ISP failed to direct care staff to do more than monitor and report AV's weakness or inability to transfer. At time of investigation, the facility failed to show documentation that safety checks were completed by staff to ensure AV's safety due to his/her change of condition. The facility's failure to provide the basic care or services necessary to ensure AV's health and safety caused AV unreasonable discomfort which is a violation of resident's rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP23-01430 $1500.00 fine assessed