- Date
- 6/7/2024
- Report number
- 00335789-AP-286761
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. Witness #1 (W1) has a history of agitation and aggression towards other residents and involvement in resident-to-resident altercations. W1 is care planned if staff see W1 approaching other residents they are to help direct W1 to a common area and offer a snack; if staff see W1 approaching other residents from behind, they are to redirect W1; if staff see W1 approaching other residents, trying to touch them, staff are to redirect W1 and take W1 for a walk; and during mealtimes staff are to assist W1 to a seat and if W1 is pacing near other residents, staff are to redirect W1 back to h/h seat and provide W1 with redirection to h/h food; W1 likes stuffed animals and baby dolls and if W1 is seen wandering, W1 can be given one of these items to keep h/h hands busy and free from hitting people. On or about May 3, 2024, interventions added during mealtimes staff are to assist W1 to h/h seat and redirect W1 back to h/h seat if W1 starts pacing near other residents; staff are to direct W1 out of the dining room and away from the other residents. On or about June 7, 2024, AV was sitting at a table in the dining room when W1 walked over and put a teddy bear on AV's walker. W1 then re-approached AV and pushed AV outside the dining room where an unwitnessed resident to resident altercation took place. W1 pushed AV, and AV was found on the floor in the doorway outside the dining room. AV complained of pain in h/h elbow. AV was taken Urgent Care where AV was prescribed lidocaine patches. The facility failed to follow W1 care plan or provide appropriate supervision in dining/common areas, which resulted in W1 pushing AV in the dining room and AV experiencing elbow pain which required medical intervention.
- Sanction
- RCFCP24-01165 $375.00 fine assessed