Violation Details: 00309416-AP-262071

Date
1/26/2024
Report number
00309416-AP-262071
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide safe environment
Result
Substantiated
Findings
The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about January 26, 2024, W1 wandered into Alleged Victim's (AV) room without permission. AV yelled for staff to get W1 out of his/her room. W1 pushed AV onto his/her bed and W1 hit AV during the incident which resulted in AV having back pain. Based on facility documentation and interviews, the facility failed to ensure that W1 saw his/her doctor regarding his/her aggressive behaviors as requested by W1's doctor on November 29, 2023, and December 2, 2023. W1 had several resident-to-resident altercations after the facility failed to ensure W1 was seen by his/her doctor on December 2, 2023. The January 26, 2024, incident was preventable and caused unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP24-00270 $1125.00 fine assessed