- Date
- 9/30/2023
- Report number
- 00295883-AP-249589
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing a fall on or about September 30, 2023, was transferred to the hospital and was diagnosed with a lumbar spine fracture. Based on facility documentation and interviews, prior to the September 30, 2023 incident, AV had multiple falls and the facility failed to service plan AV for fall risk, despite AV having 3 falls prior to incident. The facility's failure caused AV to suffer avoidable pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00169 $2500.00 fine assessed