- Date
- 4/30/2024
- Report number
- 00328252-AP-295534
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has poor gait, weakness, poor balance, and decreased mobility. AV is a one-person assist with transfers and has a 4WW but will often not use it and walk independently. AV has history of multiple falls with the last occurring on April 9, 2024 when AV fell and hit AV’s head. On or about April 13, 2024 AV had an injury fall that resulted in AV falling and hitting AV’s head, resulting in a scratch to the right side of AV’s face. Interventions put into place prior to the fall on April 13, 2024 include: If staff observe AV crouching down as if AV is going to sit ensure AV has a stationary chair behind AV; When AV is stationary in AV’s wheelchair, staff to ensure AV’s footrests are moved out of the way to allow AV’s feet to rest on the floor in case AV wants to stand up independently; If AV is observed ambulating without AV’s walker staff are to have AV sit down in a safe spot in the community and staff are to grab AV’s 4WW; When staff observe AV getting up, they are to ensure that AV’s walker brakes are locked and then unlocked when AV is ready to start walking; and During the night staff are to leave AV’s bathroom door open with the light on to allow more visualization for AV to see. On April 13, 2024 AV fell because AV got up from AV’s wheelchair and tripped over the left leg rest of the wheelchair and fell hitting AV’s head on one of the chairs. The intervention to move AV’s footrests out of the way to allow AV’s feet to rest on the floor in case AV wants to stand independently was already in place at the time of the fall on April 13, 2024. AV’s service plan was not being followed on April 13, 2024, which led to AV’s fall and AV hitting AV’s head on a chair. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00873 $500.00 fine assessed