- Date
- 2/14/2024
- Report number
- 00314398-AP-266710
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) has a known documented preexisting condition that can cause decrease ability to see clearly, write, speak, or walk. On or about February 14, 2024, the AV was found down on the floor by facility staff with no explanation as to how s/he got there. AV complained of chest pain and trouble breathing. AV was helped off the floor by facility staff, AV continued to complain of chest pain. However, due to facility staff still seeing no visible injuries they monitored AV and reported the fall to the oncoming care staff, the nurse, AV’s family, and the AV’s PCP via fax. AV continued to complain of chest pain throughout the day, and eventually taken to the hospital and diagnosed with a sternum fracture. AV sustained a total of 3 falls which occurred on or about February 02, 2024, February 04, 2024, and February 14, 2024. AV’s most recent fall is the one that is believed to have caused AV’s sternum fracture. The same interventions from the AV’s February 02, 2024, service plan were the same ones added to the AV’s February 14, 2024, service plan. There also appears to be no progressive intervention planning that took place after the AV’s fall on February 02, 2024, other than monitor for latent injuries. An intervention of grip socks was verbally mentioned as a progressive precaution, this intervention never made it to any of the provided documentation from the facility as proof that this put into practice.
The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which resulted in AV sustaining 3 falls from February 02, 2024, to February 14, 2024, and resulting in AV having an injury fall with a fractured sternum, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-01116 $1500.00 fine assessed