- Date
- 8/6/2024
- Report number
- 00347045-AP-297617
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) resides in a memory care facility and has a diagnosis of dementia. AV has a history of non-injury and injury falls. AV Service Plan, dated approximately May 8, 2024, indicates AV occasionally is disoriented, but can function independently in familiar surroundings, has poor recent memory. Fall Preventions and safety measures for falls include, uses ambulation devices: no, during the last check on NOC shift if AV is awake staff are to offer to take AV to the restroom, if staff see AV wandering the halls for long periods of time assist AV to a place to sit down, staff to make sure AV's floor is free of clutter, staff to make sure AV has AV's walker with AV at all times.
On or about July 14, 2024, AV fell resulting in a fractured left hip. AV returned to the facility on or about August 2, 2024, and fell on the same day of return. A pressure alarm on AV's bed was implemented. AV had a one-on-one caregiver from August 2, 2024, to August 4, 2024, due to restlessness and impulsivity. On or about August 5, 2024, AV had another fall. On or about August 6, 2024, AV was found on the floor of AV’s room near the doorway and AV’s nose was bleeding. AV was sent to the hospital for evaluation and was found to have a broken nose. After AV fell on August 2, 2024, an intervention was put into place for AV to have a bed alarm. A staff member’s pager was to go off when AV got out of bed. Based on the available information AV’s bed pad alarm was not in place and activated at the time of AV’s fall on August 6, 2024. AV was found on the floor by laundry staff, and the laundry staff member notified caregivers of AV’s fall via the radio. AV had time to crawl from where AV’s nightstand was to the door of AV’s room before staff were aware that AV had fallen. This evidence indicates that AV’s bed pad alarm was not in place and/or activated at the time of the fall . The facility failed to follow the care plan, failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, that lead to a fall on August 6, 2024, resulting in a broken nose, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00197 $1125.00 fine assessed