- Date
- 9/7/2024
- Report number
- 00353164-AP-304154
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim's (AV's) diagnosis include dementia and weakness. AV displays behaviors, has incontinence, balance issues, takes medications affecting balance. AV is easily distracted, has periods of altered perception or awareness of surroundings, has short-term memory loss, can be impulsive, has poor judgement and does not call for staff assistance or wait for staff to arrive prior to attempting to get up which leads to falls. AV has significant history of falls with and without injury. AV service plan indicates, one person stand-by assist for all transfers and ambulation with walker, staff to place non-slip socks on or socks and shoes. Staff to continue to stay with AV while ambulating/transferring AV to AV's preferred destination. Interventions in place include staff to remind AV to put on shoes or non skid socks when walking in AV's room or around the community, staff to ensure that AV is wearing call pendant around AV's neck and if AV does not have pendant, staff to find it and place it around AV's neck. On or about September 10, 2024, AV asked to eat dinner in AV's room and instructed staff to put dinner on AV's bed. AV later decided AV wanted AV's own food and got out of bed, started walking, got dizzy and tripped and fell over the fall mat, resulting in a thoracic spine fracture and re-opening a head laceration. AV has fallen over 10 times in a 4-month period with similar circumstances of becoming dizzy, showing symptoms of progression of dementia, and not calling for assistance when necessary. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00193 $500.00 fine assessed