- Date
- 1/16/2024
- Report number
- 00307248-AP-260091
- 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 a history of aggressive behavior with other residents, resulting in twenty-one (21) documented resident-to-resident altercations approximately between November 1, 2023, to January 12, 2024. W1's Service Plan, created after the implementation of W1's Behavior Plan, does not include any information about W1's behaviors and does not list any instructions or interventions for staff, related to W1's behaviors. All but two of W1's behavior interventions were for staff to redirect W1 away from other residents or spaces, or redirecting residents away from W1. On or about January 16, 2024, Alleged Victim (AV) was sitting in the hallway in h/h wheelchair. W1 approached AV from behind. W1 grabbed onto AV, causing AV to fall to the ground, followed by the wheelchair collapsing on top of AV. The facility failed to properly plan care, implement new behavior 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
- RCFCP24-00379 $375.00 fine assessed