Violation Details: 00323768-AP-275380

Date
4/7/2024
Report number
00323768-AP-275380
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide service
Result
Substantiated
Findings
Alleged Victim (AV) relies on the facility for his/her care, is a high fall risk, and is care planned to have a fall mat in place when in bed. On or about April 7, 2024, facility staff were alerted that AV had fell out of bed by a facility visitor. AV was unresponsive and had a laceration above their eyebrow that was bleeding, requiring AV to be transported to the hospital for stitches. According to an investigation, it was not common knowledge that AV required a fall mat, and there was no fall mat in place or in AVs room prior to the fall. The facility failed to provide services, implement interventions and / or follow AV care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-01112 $1125.00 fine assessed