- Date
- 11/16/2023
- Report number
- 00297196-AP-250929
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Witness #1 (W1) has documented acts of aggressive behavior with staff, other residents, and resident-to-resident altercations from approximately October 11, 2023, to November 15, 2023. W1's care plan did not include interventions related to W1's acts of aggressive behavior, and care plan did not include instructions, or interventions related to resident-to-resident altercations. On or about November 16, 2023, W1 had an earlier resident-to-resident altercation with another resident. Later in the day, W1 was wheeling h/h-self down the hall when Alleged Victim (AV) was walking in the opposite direction. W1 pushed AV into the wall, causing AV to slide down onto h/h butt. W1 repeatedly tried to hit AV, resulting in AV becoming emotionally upset. It took multiple staff to separate and redirect W1. The facility failed to properly plan care, implement behavioral interventions, and provide person centered interventions appropriate to mitigate W1 aggressive behaviors, resulting in ongoing resident-to-resident altercations which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00381 $375.00 fine assessed