- Date
- 5/31/2024
- Report number
- 00334783-AP-285787
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The facility failed to appropriately monitor Witness 1 (W1) according to his/her known behaviors and prior altercations. On or about May 31, 2024, Alleged Victim (AV) was watching television in the facility common area while W1 was standing near AV, with W1's back to AV. Based on facility documentation and interviews, W1 turned towards AV without provocation, and grabbed and twisted AV's right arm. During the investigation, the investigator observed that facility staff documented W1's behavioral intervention methods as being ineffective in preventing W1's behavior from escalating which placed other residents at risk of physical harm. Prior to incident, W1 had multiple events in which W1 demonstrated aggressive behavior, including physical contact with other residents and caregivers amounting to six incidents over a 3-month period. The facility's failure to properly care plan and implement appropriate behavior interventions for W1, resulted in his/her aggressive behavior escalating, causing a physical altercation with AV which resulted in pain and unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00945 $1125.00 fine assessed