- Date
- 9/10/2024
- Report number
- 00353618-AP-303956
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is a 2-person assist with transfers. AV has poor short and long-term memory and is not able to call for assistance. AV has had a total of approximately eleven (11) falls from about July 12, 2023, to approximately September 10, 2024, three (3) falls resulted in injuries.
Interventions in place on July 17, 2024, keep apartment door open to assist with preventing unsafe self-transfers, increase visual checks to 4-6 per shift and on August 26, 2024, AV was given a fall mat for use while AV is in bed. AV had a fall from bed on September 10, 2024, where AV was found lying on the floor, with the door shut, no lights on, and no fall mat in place. AV was reported to be covered in dried feces from AV's back all down AV's legs. AV had significant reddened areas on AV's left knee and head from lying on the floor for unknown amount of time. The facility failed to provide a safe environment, failed to appropriately care plan and implement reasonable interventions to address AV’s falls, and follow the interventions already in place at the time of AVs all on September 10, 2024, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-01244 $338.00 fine assessed