- Date
- 9/24/2023
- Report number
- 00287384-AP-255893
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- On or about October 14, 2023, Alleged Victim (AV) had an unwitnessed fall in his/her bedroom. AV was found on the floor, confused with the lights turned off. Based on facility documentation and interviews, AV was identified as a fall risk prior to incident and had recently returned to the facility on October 4, 2023, after an extended hospital stay due to AV's previous fall which was on September 24, 2023. AV was identified as having a significant change of condition resulting in more weakness, confusion and overall decline in most Activities of Daily Living needs. The investigation determined the facility failed to implement appropriate fall interventions to mitigate AV's fall risk, failed to properly train staff on identifying factors that could increase AV's fall risk, failed to provide oversight and monitoring of AV's change of condition, and failed to appropriately care plan related to AV's fall history. The failure resulted in AV experiencing an unwitnessed fall ten days after returning to the facility as result of another fall that occurred at facility which required hospital treatment. The facility's failure caused AV continued pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-01092 $1125.00 fine assessed