- Date
- 6/6/2024
- Report number
- 00335658-AP-286665
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- On June 6, 2024, Alleged Victim (AV) suffered an unwitnessed fall in his/her room around 2:30am resulting in a head injury. Based on facility documentation and interviews, at time of incident AV appeared disoriented, and AV's pain level was reported to be a 4 out of 10. AV was not initially taken to the hospital due to AV's family being informed that AV had fallen, resulting in a small bruise. After incident, AV continued to remain at the facility. Facility staff later observed that AV was slurring his/her words, showing a drop in his/her cognitive baseline, and AV would not eat or drink. AV was then sent to the hospital in the afternoon of June 6, 2024. Hospital medical staff stated that AV should have been sent to the hospital when the incident initially occurred due to AV possibly having a brain bleed that could cause a hemorrhagic stroke which can be potentially fatal. Based on facility documentation, AV has a known history of falls and experienced several falls in a short period of time. AV suffered eleven falls between April 10, 2024, and May 28, 2024. The facility failed to implement appropriate interventions and provide appropriate supervision related to AV's known history of falls. As a result, AV experienced several unwitnessed falls, causing unreasonable discomfort, and a hospitalization. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00771 $3000.00 fine assessed