- Date
- 1/26/2024
- Report number
- 00310194-AP-262966
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a poor gait, decreased ROM, weakness, poor balance and decreased mobility. AV has a history of falls with a broken hip. AV is blind and has [progressive eye disease]. AV is only able to see shadows. AV utilizes a wheelchair and a walker for assistance with ambulation and transfers. AV can't remember to press the button [on the call light]. Staff report AV has never been able to use the call light themself to ask for help. On or about January 13, 2024, documentation indicates AV has been having issues with pendant, AV can’t feel the button to call staff when needing assistance. AV needs help going to the bathroom but can’t get ahold of staff due to not being able to see how to push pendant due to being blind. According to AV’s service plan, interventions in place at the time of the fall included ensuring that AV’s dresser is against the wall and farther from h/h bed so that AV is unable to get h/h foot stuck, staff to ensure all liquid is cleaned from AV’s apartment floor prior to standing or ambulating, and staff to ensure that AV has a clean brief in place prior to leaving the bathroom and make sure AV had the call light or pendent. On or about January 26, 2024, at approximately 0615 AV was found on the floor next to h/h closet sitting on h/h bottom scooting towards the bed/door area. AV had been confused the night prior and had refused assistance to go to bed. AV had been toileted at 0530 prior to the fall, it is believed that AV had tried to transfer themselves out of their wheelchair. Interventions put into place include staff to provide safety checks for AV upon rising, before and after meals and at bedtime, which were not much different than interventions put into place on or after January 17, 2024, fall that included Staff to assist AV to the bathroom at bedtime and no less than 2 times per night shift as well as AV request or as needed. On or about January 26, 2024, at approximately 0830 AV was found on the floor of h/h room next to h/h wheelchair. At the time of the falls on January 26, 2024, AV did not report pain and staff were unaware that AV had an injury as a result of the falls. On or about January 28, 2024, AV began reporting pain in h/h side. On or about January 31, 2024, AV was taken to urgent care where s/he was diagnosed with rib fractures. The facility failed to plan care around AV’s needs, implement reasonable effective interventions that are person-centered to mitigate AV’s ongoing falls with injury, resulting in two falls on January 26, 2024, one of which resulted in physical harm to AV when s/he experienced pain in h/h side and fractured ribs.
- Sanction
- RCFCP24-00899 $250.00 fine assessed