- Date
- 1/1/2024
- Report number
- 00304966-AP-257897
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- On or about January 1, 2024, Alleged Victim (AV) entered Witness 1 (W1's) room. W1 became upset, grabbed AV by h/h wrist and arms and shook AV. Staff intervened and redirected the residents. Both AV and W1 were upset by the interaction. AV is independent with ambulation and frequently wanders into other residents' rooms. W1 has significant past trauma that is triggered by other residents entering h/h room, causing h/h distress. W1 is able to lock h/h door independently and staff are to help make sure W1's door is locked. Staff checked in with W1 in h/h room 5-15 minutes prior to the resident-to-resident with AV. Incident reports from January 1, 2024 indicate that AV's and W1's service plans were followed at the time of incident, but W1's door was not locked as per h/h service plan. The facility failed to follow the care plan, placing AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00915 $338.00 fine assessed