Violation Details: 00297553-AP-251111

Date
10/9/2023
Report number
00297553-AP-251111
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
Result
Substantiated
Findings
On or about October 9, 2023, in the early morning hours, Alleged Victim (AV) was found lying on their right side next to his/her bed. AV was noted to have a laceration on his/her scalp and was sent to the hospital for treatment. Medical staples were used to close the laceration on AV's scalp. Based on facility documentation and interviews, AV is a full assist with mobility and a two-person transfer assist. At time of investigation, facility staff could not identify staff on shift to determine if AV's safety plan was being followed at time of incident. The facility's failure to ensure AV's care plan was being followed resulted in AV ambulating without assistance causing AV to fall and suffer a head injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP24-00973 $1500.00 fine assessed