Violation Details: 00290484-AP-244490

Date
10/9/2023
Report number
00290484-AP-244490
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. On or about October 9, 2023, AV fell and sustained a hip fracture. Based on facility documentation and interviews, AV had previous falls on April 17,2023, July 1, 2023, July 28, 2023, and August 8, 2023; four of these five falls occurred in AV's bathroom. The facility's failure to implement fall preventions/interventions regarding AV's care needs with toileting and mobility assistance to and from the bathroom, caused AV to experience multiple falls, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP23-01506 $1125.00 fine assessed