Violation Details: 00322041-AP-273888

Date
3/29/2024
Report number
00322041-AP-273888
Type
Abuse: Neglect
Level
4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation
Failed to follow care plan
Result
Substantiated
Findings
According to the documentation, the facility failed to follow the care plan for the Alleged Victim (AV) who is a known fall risk. On or about March 29, 2024, at approximately 6:30 am, the AV was found on the floor, and it appeared the AV was left in their wheelchair all night and not placed in bed with proper fall interventions in place. The bed was observed to be undisturbed and noted the resident did not sleep in their bed the night previous and was left in their wheelchair all night. The failure resulted in the AV to slide out of their wheelchair suffering a fractured hip which required surgery, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP24-00423 $2500.00 fine assessed