- Date
- 1/19/2024
- Report number
- 00307846-AP-260679
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to answer call light in a timely manner
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a diagnosis of dementia with behavioral disturbances. AV's behaviors include AV yelling or screaming. AV's active trigger for h/h behaviors is being left alone. Interventions include bringing AV to an activity, sitting, and talking with AV, letting AV know s/he is safe, offering AV a snack. AV just wanting someone to sit with h/h. Staff (W3, W4, W5) reported, other staff members would intentionally ignore or delay responding to AV's call lights. AV's call light was activated a total of 172 times between the dates of December 25, 2023, and January 25, 2024. Only 54.65% of AV's call lights were resolved within 45 minutes and 11.63% of AV's call lights took longer than four hours to be resolved by staff. Witness 3 (W3) reports Management was aware of the concerns that AV's call lights were being ignored, but did not address these concerns in an impactful way and Witness 5 (W5) reports the facility has put in place one-to-one staffing for other residents with behavioral needs, but did not for AV as AV's behaviors were so consistent and there was not enough staffing to allow for staff to sit with AV.
The facility failed to meet resident scheduled and unscheduled needs by evidence as being unable to respond to call lights in a timely manner, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00535 $500.00 fine assessed