- Date
- 9/7/2024
- Report number
- 00353164-AP-304165
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV)'s diagnoses include dementia and weakness. AV displays behaviors, has incontinence, balance issues, takes medications affecting balance, has a diagnosis that contributes to falls. AV is easily distracted, has periods of altered perception or awareness of surroundings. AV has short-term memory loss, AV 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. AV service plan indicates AV will need one person stand by assist for all transfers and ambulation with walker. Staff to place on non-slip socks or socks and shoes. Staff to continue to stay with AV while ambulating/transferring AV to AV's preferred destination. AV has history of injury and non-injury falls. On or about July 21, 2024, AV fell in h/h room and showed signs of increased confusion and could not tell staff how s/he fell. AV had pain in back and head and went out with EMTs On or about July 22, 2024, AV was in AV's room self-ambulating when something fell under the bed and AV tried to pick it up, lost balance and fell resulting in a skin tear on AV's right arm and pain in the head . The facility failed to put into place person-centered interventions to prevent AV from falling. AV had fallen the day before in similar circumstances. AV was showing signs of increased confusion, has short-term memory loss and a history of falling in AV's apartment. The intervention of AV using a pendant to call for assistance was proven ineffective in a situation where AV drops an item and attempts to pick it up, then loses balance and falls. The facility did not address AV's behavior of falling, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00193 $500.00 fine assessed