- Date
- 9/24/2023
- Report number
- 00287384-AP-241573
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- On or about September 24, 2023, Alleged Victim (AV) suffered an unwitnessed fall and was found on the floor in the bathroom, next to the shower, with shower curtain almost completely pulled off, with blood on AV's bathmat and the floor of the shower. AV had two bump abrasions on the left side of AV's forehead. AV was sent to the hospital for treatment. Based on facility documentation and interviews, prior to this incident, AV suffered another fall with injuries three days prior to this incident. The investigation determined the facility failed to provide appropriate services according to AV's care needs by not developing and/or maintaining a comprehensive care plan for AV's fall risk and by not ensuring staff were properly trained on AV's care needs before leaving AV alone. The facility's failure caused AV unreasonable discomfort when AV fell and hit their head. The facility's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.
- Sanction
- RCFCP24-01092 $1125.00 fine assessed