Violation Details: 00355081-AP-305631

Date
9/17/2024
Report number
00355081-AP-305631
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
Alleged Victim (AV) relies on the facility for his/her care. AV uses a wheelchair or walker for ambulation, requires staff assistance with transfers, and has history of falls. AVs care plan directs AV to use his/her call button for help, but also indicates AV cannot remember to use the call button and AV's behavior plan states that AV should be kept within line of sight to reduce falls. According to an investigation, on or about September 17, 2024, AV was found on the floor in AV's room by care staff, resulting in a skin tear and bruising to AV's right forearm. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-00410 $375.00 fine assessed