- Date
- 4/22/2024
- Report number
- 00328021-AP-279697
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a history of falls, approximately 11 falls between February 10, 2024, to April 23, 2024. AV Service Plan dated on or about February 06, 2024, states AV is independent with transfers from bed, chairs, couch, toilet, but may require some assistance during the time AV was healing from fractures , AV is able to ambulate safely with a four-wheeled walker and staff are to encourage AV to use the walker if AV is seen without the walker. A temporary service plan dated on or about February 13, 2024, indicates staff to make sure AV has fall alarm attached at all times. Temporary service plan date on or about April 3, 2024, indicates staff to complete checks on AV every twenty minutes while AV is seated in main TV room to ensure AV's needs are met. AV had a fall on or about April 19, 2024, resulting in a large hematoma a concussion. On April 22, 2024, AV was found in the TV room sitting on h/h bottom. AV's pressure alarm was on but did not make a sound. On April 23, 2024, AV call light went off and AV was found lying on h/h right side. AV did not have socks on, and AV stated s/he was heading to the bathroom when s/he slid onto the floor. At the time of the fall AV care needs related to ambulation and transferring had increased. AV was no longer able to ambulate with a walker and required a wheelchair. The facility failed to put effective interventions in place to mitigate AV's continued falls, and did not update AV's service plan to reflect AV's change in condition relating to AV's fall risk and ambulation needs, which is a violation of resident’s rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00859 $500.00 fine assessed