- Date
- 3/3/2024
- Report number
- 00316664-AP-268781
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) Service Plan indicates AV is independent with ambulation and the use of a 4-wheeled walker, but relies on staff to remind h/h to use 4-wheeled walker Service Plan. AV has a has exit seeking behaviors and has a history of elopement from Facility. On or about March 03, 2024, at approximately 5:40 p.m. AV went into another resident's room, took the window out of the tracks, kicked the screen out, and eloped from facility. There is a history of three elopements from Facility on or about February 12, 2024, February 15, 2024, and 03/03/2024. There are no new interventions implemented after elopements documented, and one-to one staff intervention was not implemented until March 03, 2024. One-to-one intervention was not implemented in a timely fashion and with only limited times, leading to AV elopement on March 3, 2024. The facility failed to implement appropriate interventions after prior elopements, and failed to have a safe environment placing AV at risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00872 $375.00 fine assessed