Violation Details: 00346960-AP-297348

Date
8/6/2024
Report number
00346960-AP-297348
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
According to the documentation, the facility failed to properly care plan for Witness 1’s (W1) known aggressive behavior starting in the afternoon. According to an assessment, W1 is known to have sundowning behavioral issues in the afternoon but did not specify what kind of behaviors for staff to be aware of. On or about august 06, 2024, staff heard screaming coming from the Alleged Victim’s (AV) room. As staff entered the room, staff witnessed W1 straddling the AV, their hands around the AV’s neck and was strangling them. Local law enforcement was called, and they took W1 to the hospital on a police officer hold and deemed W1 a danger to other residents. There were no interventions on W1 service plan or signs to look for to prevent a resident-to-resident altercation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP24-01205 $338.00 fine assessed