- Date
- 11/23/2023
- Report number
- 00311799-AP-280509
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) Service Plan indicates AV is independent in transferring and ambulation and uses a walker to ambulate. AV has a history of falls. Hospital record on or about November 18, 2023, indicates AV had a fall two days ago and was having back pain. AV had two falls on or about November 22, 2023, requiring staples to h/h scalp. Staff observed that AV had become more unsteady approximately one week before s/he began falling on or around November 18, 2023, but the facility did not put any interventions in place to address AV’s decline in mobility. After the first fall on November 22, 2023, interventions put into place to address AV’s risk of falls include if staff see AV wandering around for long periods of time they are to offer for h/h to sit down in a chair in a common area. The intervention put into place after the first fall on November 22, 2023, was not an appropriate intervention. After the second fall on November 22, 2023, interventions put into place to address AV’s risk of falls include if staff see AV standing up to ambulate in the dining room they are to offer assistance. Interventions able to be recalled by witnesses to reduce AV’s risk of falls include frequent checks. The incident reports for AV’s falls state, “Staff and family are aware that AV can be unbalanced” . There is no service planning around AV’s balance issues and no directions are given to staff on how to assess AV for balance issues or what to do if AV is seen to be having balance issues. On or about November 23, 2023, at approximately 3:09 pm AV was found on the floor in the hallway. EMS was called to assess AV and after consulting with AV’s POA it was decided that AV should stay at the facility. On November 24, 2023, AV was sent to the hospital due to pain. After imaging, AV was found to have burst and compression fractures of the spine. AV was signed onto hospice services and returned to the facility. In AV’s evaluation dated on or about November 27, 2023, it is stated that there are “no signs of fall issues”. The interventions put into place on November 22, 2023, were not communicated clearly to staff. In AV's service plan dated October 27, 2023, and in AV's evaluation dated November 27, 2023, AV is described as independent with ambulation and transfers. There is no evidence that the new expectations that staff should assist AV if AV is seen walking for extended periods of time, and that staff should assist AV if AV is seen ambulating in the dining room, were communicated to staff. The facility failed to appropriately care plan and implement reasonable person-centered interventions to address AV’s unbalance and to mitigate the risk of further falls, which resulted in a fall on November 23, 2023, resulting in AV being transferred to the hospital on November 24, 2023, and diagnosed with compression fractures of the spine, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-01283 $1500.00 fine assessed