- Date
- 8/8/2023
- Report number
- 00294368-AP-248142
- 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 September 11, 2023, indicates AV requires staff to take h/h to the dining room for meals, has poor gait, has an assistive device of walker or wheelchair, AV needs transferring assistance daily, AV is a one person transfer assist to and standing position, 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, After dinner staff are to walk AV back to h/h room, if staff see AV without h/h walker they are to stay with AV as they are to radio for someone else to get AV's walker. On or about September 15, 2023, TSP indicates staff are to offer to help AV back to h/h room to rest if s/he is wandering after a meal. On or about September 18, 2023, AV was in the unassisted dining room, AV was getting up from h/h chair in the dining room without using h/h wheelchair or walker, AV had socks on, and lost h/h balance falling forward and hit head on the ground. The facility failed to provide a safe environment and follow AV's care plan, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00247 $1000.00 fine assessed