- Date
- 9/17/2023
- Report number
- 00287162-AP-241391
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) service plan: AV will sometimes refuse care, or gets angry when staff try and help h/h in the evening. On a scheduled medications for behaviors. AV requires minimal assistance. Mobility: Minimal Assistance 2 person. AV ambulates independently with walker, sometimes forgets walker. AV requires staff assistance with bathing twice weekly in the evenings. Staff will need to turn on the shower, assist AV getting h/h clothes off, hand h/h soapy washcloth and have h/h wash all areas that s/he can, assist AV with the shampoo and have h/h scrub and rinse h/h hair, help get completely dry, assist with putting clothing on. AV will sometimes refuse to take h/h shower or get really upset when staff is trying to shower h/h. If this occurs, make sure AV is in a safe area and walk away and try again at a later time. On or about September 17, 2023 AV had become agitated after a shower and began to walk out of the shower. AP2 turned to get AV a towel, AV lost AV's balance and stumbled backwards. AP2 attempted to assist AV and catch AV's balance but AV began to slip causing AV and AP2 to fall backwards. AV fell on top of AP2. EMTs took AV to the hospital and AV was diagnosed with a hip fracture. The facility failed to properly care plan and have clear instructions for staff, which resulted in serious harm to AV, which is a violation of resident’s rights is neglect of care and constitutes abuse.The allegation that AP2 failed to provide supervision or safety for AV, was investigated and the determination was not substantiated.
- Sanction
- RCFCP24-00850 $500.00 fine assessed