- Date
- 3/14/2024
- Report number
- 00318814-AP-270782
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The facility failed to implement appropriate interventions and failed to provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. Based on facility documentation and interviews, AV fell 3 times in the span of six weeks. It was determined that after each fall, the facility failed to put new timely fall interventions in place and facility failed to assist AV with mobility resulting in AV suffering a fall that resulted in a head injury. After AV's March 4, 2024, fall AV was sent to the hospital for treatment in which AV was diagnosed with a brain bleed. Facility documentation states that AV suffered falls on February 4, 2024, March 4, 2024, and March 11, 2024. AV's medical documentation states that AV's February 4, 2024, fall caused a bruise to AV's face as well as a brain bleed that was not diagnosed until the March 4, 2024, fall incident that resulted in hospitalization. The facility's failure to properly care, resulted in AV experiencing several unwitnessed falls, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00661 $1125.00 fine assessed