Violation Details: 00330864-AP-282141

Records Request Print
Date
5/11/2024
Report number
00330864-AP-282141
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(A)
External site: 411-054-0036(2)(g)
External site: 411-054-0070(1)
Findings
Alleged Victim (AV ) is a high fall risk with a history of falls. AV Service Plan is a one (1 ) person assist stand by transfer and AV uses manual wheelchair due to weakness in self-propelling. AV's ability to use the call light is unreliable. On or about May 11, 2024, AV called for assistance and waited 18 minutes. AV was tired of waiting and started to self-transfer. AV fell while attempting to self-transfer from a recliner to h/h wheelchair. Caregiver came back from lunch and found AV sitting on the floor upright in front of recliner chair with back leaning on the chair. AV sustained bruising to h/h tailbone area. The facility failed to provide a safe environment, answer call light in a timely manner and sufficient direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident, providing services for residents that include assistance with activities of daily living, supervision, and support.
Sanction
RCFCP24-01120 $375.00 fine assessed