- Date
- 8/12/2024
- Report number
- 00347913-AP-298230
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) service plan dated on or about July 11, 2024, indicates AV has history of a brain aneurysm, forgets many things including recent events, is able to make desires and needs known, is unable to make big decision, staff must contact POA for important matters, has history of falls prior to moving to the facility, ambulates with walker independently, sometimes forgets about h/h walker and staff to remind AV to use walker for safety. AV has a VP Shunt, per AV family, if AV falls in the future, call 911 immediately to make sure there is no damage to AV's VP shunt from the fall. On or about August 1, 2024, AV was found lying on floor by bathroom on h/h stomach. AV reported "I fell on my way to the bathroom last night" and reported back pain and hip pain. AV refused 911. AV continued to complain of pain from approximately August 1, 2024, to August 6, 2024. On or about August 6, 2024, AV had an appointment and Xray’s. AV was diagnosed with a spinal fracture and UTI. The facility failed to follow the service plan, by not calling 911 immediately after a AV's fall to make sure there is no damage to AV's VP shunt, and not contacting AV POA for important matters, and letting AV refuse staff to call 911, as AV is unable to make big decision, resulting in AV not receiving timely medical attention, and being in unreasonable discomfort, which is a violation of resident’s rights is neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00322 $500.00 fine assessed