- Date
- 8/29/2024
- Report number
- 00351743-AP-302086
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a history of falls, balance problems, physical weakness and decreased awareness. AV is on hospice, does not know how to use call button or utilize call system and has a four wheeled walker but refuses to use it. AV service plan dated on or about July 19, 2024, indicates AV ambulates independently within the community but requires occasional staff assistance with balancing. Staff to provide assistance by walking AV to meals and activities. If AV observed unbalanced, staff to assist with hands on steadying, walk with AV to destination, and encourage AV to sit down and rest. Staff to assist AV to bathroom upon rising, before and after meals, at bedtime, as needed and at least once per night shift. Fall interventions include nonskid socks, rubber soled shoes, ensuring shoes are tied, ensuring AV feels chair behind AV before sitting, ambulation with walker when AV allows, redirection, proper positioning in chairs and bed, apartment free of clutter and ensuring AV isn't wrapped in blankets, during the night staff to ensure that AV's bathroom light is on and bathroom door is open for AV to have more visualization. AV continued to fall with interventions of frequent check, toileting schedule, clear pathways, lighting, and fall mat. On August 21, 2024, intervention in place was to hire staff for 1:1 care for AV to prevent future falls. AV had an additional two falls on August 24, and 26, 2024 prior to the fall on August 29, 2024, when AV woke up and attempted to get out of bed tripping over the fall mat. The facility recognized AV needed 1:1 care to prevent falls, but did not implement intervention. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increase and ongoing falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00218 $375.00 fine assessed