- Date
- 8/8/2023
- Report number
- 00294368-AP-248138
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a history of falls and is not consistent with using a cane or a walker. AV Service Plan, dated June 19, 2023, indicates AV has poor gait, has an assistive device of cane or walker, staff are to make sure that AV has AV's walker next to AV or within reach for safety. And AV can choose what ambulation device. Fall prevention included staff are to check on AV no less than 4 times a shift and when AV is weak or tired encourage h/h to use walker instead of a cane. On or about September 1, 2023, AV was trying to open another resident’s door when s/he fell and hit h/h head on the doorway. AV has had previous falls when trying to enter into other residents rooms. There are no TSP to address AVs ongoing falls until September 5, 2023. The facility failed to 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
- RCFCP25-00246 $500.00 fine assessed