Violation Details: 00354245-AP-304572

Date
9/12/2024
Report number
00354245-AP-304572
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Findings
The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about September 12, 2024, AV fell while wearing socks that were worn down and lacked proper grip. AV's service planned interventions were for staff to ensure AV was wearing non-skid socks when providing safety checks every two hours. The facility did not develop or implement any known changes to AV's care plan following the falls. The facility failed to follow the care planned fall interventions to address AV’s fall risk, resulting in a fall with skin tear. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
RCFCP25-00853 $188.00 fine assessed