- Date
- 10/7/2023
- Report number
- 00292520-AP-246434
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is minimally oriented and relies on facility staff to ensure that h/h personal care, safety, and supervision requirements are met. AV moved into the facility with a known fall history. AV has a history of getting out of bed and often gets out of bed and wanders. Most of AV’s falls are at night. Interventions in place to reduce AV’s risk of falls at the time of the incident included: If staff see AV without h/h walker for extended periods of time they are to offer for AV to switch to h/h wheelchair and get them a snack; Staff are to offer to help AV back to h/h room to rest if s/he is wandering after a meal; In the evenings when AV is wandering staff are to offer for h/h to sit with another resident in the dining room; Staff to offer to take AV back to h/h room after breakfast or to escort h/h to an activity; If staff see AV standing they are to walk directly to h/h and help AV to sit down then take h/h to the location of h/h choosing; Staff are to make sure during each check that AV's blankets are tucked in at all times; Staff to make sure they offer to change AV's clothes when putting h/h to bed as s/he allows. On October 7, 2023, staff observed AV scooting on h/h bottom in the hallway. It is believed that AV fell out of bed. AV was sent to the hospital due to a large bruise on the right forehead and altered mentation. At the hospital AV was diagnosed with a closed head injury. There is no service planning and interventions in place to mitigate the risk of AV getting out of bed at night and falling at night or instructions to staff on how to care for AV when s/he gets out of bed and wanders at night.
The facility failed to provide a safe environment, appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00554 $1500.00 fine assessed