- Date
- 4/10/2024
- Report number
- 00324735-AP-276567
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is independent in ambulation and transfers. AV has a history of injury and non-injury falls. Following AV's injury fall on March 18, 2024, an Interim Service Plan was initiated directing staff to move AV to the middle of h/h bed, if AV is observed sleeping on the edge of h/h bed. AV's Service Plan, dated February 18, 2024, already listed staff ensuring that AV is positioned in the middle of h/h bed as an active fall prevention intervention. On April 10, 2024, staff found AV on the floor of h/h room; AV had immediate bruising to h/h forehead and open bleeding abrasions to h/h forehead and bridge of h/h nose. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00818 $500.00 fine assessed