- Date
- 2/23/2024
- Report number
- 00316118-AP-268289
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- According to the documentation, the facility failed to update the Alleged Victim’s (AV) care plan for their repeated falls and moderate fall risk. From about December 05, 2023, through February 23, 2024, the AV experienced approximately five (5) injury and non-injury falls. On or about February 23, 2024, the AV was walking with a group of residents from one building to another from an activity. During that walk, the AV’s walker got stuck in a crack causing the AV to fall. The AV was sent to the emergency room where they were diagnosed with a fractured hip. The family elected to have surgery to repair the fractured hip. The AV did not recover well post operation and subsequently passed away. The AV was a known fall risk and was listed as a moderate fall risk on their service plan. The AV experienced an increase in the number of falls and there was no documented evidence the facility implemented interventions to prevent future falls. The failure to update the AV’s service plan with appropriate progressive fall interventions is a violation of resident rights is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00133 $1125.00 fine assessed