- Date
- 12/12/2023
- Report number
- 00301767-AP-255012
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has documentation indicating between January 1, 2023, and December 11, 2023, to have experienced approximately 15 falls. AV has history of a fall on October 19, 2023, when AV wandered into a peer’s room and was found lying on h/h side after attempting to sit on a recliner. Service Plan dated September 11, 2023, indicates AV requires extensive assistance in mobility and ambulation. AV has a four wheeled walker that s/he uses for ambulation; AV is known to be forgetful about using h/h walker; AV requires two-person staff assistance with transfers. AV has a history of falls, decreased awareness, and balance problems and AV has had three or more falls in the last 30 days. Fall Prevention and interventions include, staff are to provide verbal cueing and direction along with escorts to and from meals and activities; If AV is seen weak or unsteady, staff are to escort AV to a point of safety and staff are to ensure that AV is wearing proper footwear. The fall prevention interventions listed by the facility are re-worded iterations of the same concepts, including seven statements about ensuring AV is using h/h walker correctly, four statements about ensuring AV is toileted regularly, three statements about clutter or trip hazards, and two statements each about proper footwear and intervening when observing AV ambulating while weak or unsteady. On or about December 12, 2023, at approximately 1845 hours, AV fell while independently ambulating and attempting to sit in a chair; AV fell off the chair, hitting h/h head on the wall, and fell to the ground. AV reported s/he was in pain; EMS was called, and AV was transported to the ER where s/he was diagnosed with fractures to h/h T6 and T7 vertebrae.
The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00521 $1500.00 fine assessed