Violation Details: 00341757-AP-292453

Date
7/12/2024
Report number
00341757-AP-292453
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Findings
According to the documentation, the facility failed to follow the care plan for the Alleged Victim (AV) to transfer to their recliner to prevent future falls out of their wheelchair. On or about May 28, 2024, the AV fell asleep in their wheelchair and suffered a fall. A temporary service plan was created to transfer the AV out of the wheelchair and into the recliner to prevent future falls out of their wheelchair. On or about July 8, 2024, the AV was left in their wheelchair and the AV fell out suffering a fall and sustaining an open wound on their head. On or about July 12, 2024, the AV was left in their wheelchair again and they fell out and suffered a head laceration. The failure to follow the care plan led to multiple injury falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP24-00884 $188.00 fine assessed