- Date
- 6/30/2024
- Report number
- 00339671-AP-290494
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Witness #1 (W1) Service Plan dated on or about May 22, 2024, indicates W1 is diagnosed with agitation, dementia without behavioral disturbance. W1 Active Triggers are when someone comes into W1's room and W1's space. Staff are too direct W1 and ensure W1 stays on W1 side of the room, have a labeled sign above W1's bed and W1 needs to be reoriented to W1's apartment and surroundings in the neighborhood. W1 forgets W1 has a roommate . W1 has a history of resident-to-resident altercations. Alleged Victim's (AV's) Service Plan dated on or about June 26, 2024, indicates AV is anxious, has anxiety disorder, and is sometimes assaultive. AV has no active triggers. AV keeps to self for the most part and in between meals, AV likes to rest. On or about June 30, 2024, staff heard W1 yelling from W1 and AV's room. Staff found AV holding W1's arms to stop W1 from punching AV in the face. W1 hit AV by punching AV in the face multiple times. From March 2024-June 2024, there are at least two documented resident-to-resident altercations in which W1 made physical contact with a resident in a room. There is no specialized signage at AV/W1's door nor any specialized signs to assist W1 to locate W1's bed in the room as directed in W1's service plan. The facility failed to provide a safe environment, and follow the W1's care plan, placing AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-01292 $375.00 fine assessed