- Date
- 8/7/2024
- Report number
- 00347371-AP-298013
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is a high fall risk with a history of unwitnessed falls. AV's service plan dated approximately August 4, 2024, indicates AV is a 1-person assist for transfers into wheelchair, uses a wheelchair for all ambulation, and is a 1-person assist with pushing AV's wheelchair. AV's fall precautions/interventions indicate, keep all walkways & hallways free of clutter, wear non-slip shoes, slippers or socks, motion sensor to notify staff when AV is ambulating in apartment, care staff to check in with AV and ensure safety. Motion sensor placed in bathroom, staff to check on AV and offer assistance with toileting when bathroom sensor goes off. Ensure there are no items in front of the motion sensor at the head of the bed. Breaks to be locked and wheelchair placed at bedside. As needed treatments indicate, Fall Mat per Hospice okay to use while in bed, monitor for safety. On or about August 7, 2024, AV was found on the floor next to AV's bed. AV sustained an abrasion on AV's left cheek and AV's left eye was swollen. Alleged Perpetrator 2 (AP2) failed to follow AV service plan, the facility failed to provide adequate supervision, and training over AP2 to ensure AV service plan was being followed. AV was found on the floor, fall mat was not in place, AV's wheelchair was not within reach of AV and the breaks were not locked. AV's motion sensor had not activated when AV fell. AP2 reported, AV refused to allow AP2 to place the fall mat, AP2 did not document the refusal or notify proper staff. AP2 was trained on service plans, and dementia. AP2 was not trained on abuse, or documentation, per AP2's training file, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00311 $375.00 fine assessed