- Date
- 8/28/2023
- Report number
- 00282605-AP-237056
- 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 his/her care. AV has difficulty walking due to the loss of use on one side, drags one foot and is unsteady. AV’s service plan dated July 30, 2023, indicates AV is independent with transfers, ambulation; and uses a walker to assist with ambulation. AV has a fall history and had approximately thirty-six (36) falls between July 5, 2022, and August 22, 2023. On or about August 28, 2023, AV hit h/h shoulder on the door frame of the bathroom which caused AV to lose h/h balance and fall to the ground resulting in AV breaking h/h humerus bone. AV had two (2) additional falls on August 29, 2023, and a fall on August 30, 2023, all resulting in pain. The facility failed to provide a safe environment and implement appropriate interventions to mitigate AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00171 $1125.00 fine assessed