- Date
- 1/17/2024
- Report number
- 00310194-AP-278257
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate 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 CP when needing assistance. AV needs help going to the bathroom but can’t get ahold of us due to not being able to see how to push pendant due to being blind. On or about January 17,2024 AV was found on the floor between the end of h/h bed and the dresser. AV’s left foot was on one side of the dresser while h/h right foot was on the other side of the dresser and stuck underneath arch of the dresser at the bottom. AV reported that s/he fell trying to get to the restroom. AV had redness and pain to the top of h/h right foot and back. The interventions put into place to reduce AV’s risk of falls that witnesses were able to recall included completing frequent checks on AV, ensuring AV was in a common area, and toileting AV frequently. The facility failed to properly plan care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00899 $250.00 fine assessed