- Date
- 3/8/2023
- Report number
- 00319242-AP-271135
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for care and supervision. AV service plan date on or about December 27, 2023, interventions staff to reposition, transfer from a wheelchair to a bed or another chair. If AV exhibits anxiety by restlessness, trying to get up and down from wheelchair and chair, staff will report and document behaviors that may arise. AV requires a full escort to meals and activities; staff will encourage AV to come into the community areas for increased supervision while awake. AV is not able to use the community call system while in AV's room to alert staff to AV's needs. AV’s primary language Japanese and does not have the ability to understand and be understood. AV speaks Japanese, and AV at times will respond in English with yes and no questions or simple responses. AV can still understand English. AV has poor ambulation gait, decreased ROM, decreased mobility AV uses Assistive Devices (AD), Wheelchair, and hospital bed. AV primarily uses AV's wheelchair and cannot self-propel; AV will need one staff member to assist AV with transfers in and out of the wheelchair. AV has history of falls, balance problems, physical weakness. AV has decreased awareness, medications affecting balance, and a diagnosis that would contribute to falls. Fall preventions include staff will encourage AV to be out in the common area while awake for increased supervision, staff will ensure AV is assisted to a common area or has a tabletop activity to keep AV engaged while the staff is assisting other residents. Staff to set AV up with activity while AV waits for dinner. Staff to keep pathways clear, and clutter picked up in room and common areas. Staff to ensure AV has non-skid footwear for transfers. On or about March 8, 2024 , AV was escorted by staff to the common area to watch TV. AV tried to stand up, AV sat back down, and then got up again and attempted to walk, and AV was found on the floor. AV was diagnosed with Fracture to L3 Vertebrae.
AV’s Service Plan has contradicting statements on AV ability to communicate needs, AV "doesn’t have the ability to understand and be understood"; contradictory to, "AV speaks Japanese, and AV at times will respond in English with yes and no questions or simple responses. AV can still understand English". In interviews staff report contradicting statements on how AV communicates h/h needs, when AV wants assistance, AV will let the staff know with head nods and hand gestures; AV speaks mainly in AV's native language, AV understands English. AV's Service Plan describes AV's mobility and Assistive Devices as, "Wheelchair, and hospital bed. AV primarily uses AV's wheelchair and cannot self-propel; AV will need one staff member to assist AV with transfers in and out of the wheelchair." contradictory to interview from staff AV using a walker, AV is encouraged to use a walker and wheelchair, AV ambulates with a walker, AV uses a wheelchair for mobility and identified by observation noted by APPS in video of incident on or about March 8, 2024, AV's walker was beside AV, AV reaching for AV's walker, AV grabbing AV's walker losing AV's balance and falling to the floor. AV service plan indicates AV has poor ambulation, gait, decreased ROM, decreased mobility. AV has history of falls, balance problems, physical weakness. AV has decreased awareness, medications affecting balance, and a diagnosis that would contribute to falls. Fall preventions include staff will encourage AV to be out in the common area while awake for increased supervision. The facility failed to provide a safe environment for AV known gait disturbance and fall history by not providing the proper supervision when in the common area. The facility failed to properly plan care around AV's ability to communicate and make AV needs known, when AV is known to use hand gestures and head nods to get staff attention and only speak in native tongue and failed to care plan around AV using a walker with known mobility issues. The facility failed to follow the care plan by not assisting with transfers and providing supervision in the common area.
- Sanction
- RCFCP25-00266 $1500.00 fine assessed