Violation Details: 00305285-AP-258222

Date
12/3/2023
Report number
00305285-AP-258222
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
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 an unwitnessed fall on or about December 3, 2023, was transferred to the hospital, and diagnosed with rib fractures. Based on facility documentation and interviews, AV has a history of falls. AV suffered two falls prior to incident. In both of falls prior to incident, AV suffered injuries and the facility failed to appropriately document interventions related to preventing falls when ambulating. The facility failed to appropriately care plan and implement reasonable person-centered fall interventions to address AV's prior falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP24-00457 $1125.00 fine assessed