- Date
- 10/26/2023
- Report number
- 00293170-AP-247006
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide inservice
- Result
- Substantiated
- Findings
- According to the documentation, the facility failed to provide in-service training to the staff for the usage of that bed alarm for the Alleged Victim (AV). From approximately August 10, 2023, through October 24, 2023, the AV had approximately 13 documented falls at the facility. One of the interventions was to implement a bed alarm that was connected to the phones of the facility’s call system. From approximately October 03, 2023, through October 24, 2023, the bed alarm was activated approximately 79 times with documented response times ranging from 8 seconds to 23 hours approximately. On or about October 25, 2023, at approximately 5:40 am, the AV was found on the floor in their room with a red liquid leaking from their head. Paramedics were called and pronounced the AV dead at the scene. Upon review of the bed alarm, it was noted the bed alarm was activated at approximately 10:45 pm and was not answered until approximately 6 hours and 56 minutes later at around 5:41 am when the AV was found. According to witness statements from staff members of the facility, they were never trained on the bed alarm system and did not know how to use if effectively. The failure to train staff on how to operate the bed alarm to ensure resident safety is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00174 $2500.00 fine assessed