- Date
- 9/22/2024
- Report number
- 00355875-AP-306219
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) moved into the facility approximately February 2022. When AV first moved into the facility, staff followed AV without AV's knowledge, to see if AV could go on walks and get back to the facility. AV service plan dated on or about August 29, 2024, indicates AV has dementia, AV's short-term memory is not good and needs redirection often to find AV's apartment and find AV's way from activities. AV is independent with ambulation. AV wore a wander guard when AV first came to the facility due to leaving the facility and not finding AV's way back. AV no longer wears wander guard, staff to let the nurse know if AV leaves facility and cannot find AV's way back. On or about September 22, 2024, at approximately 7:00 am AV was in AV's apartment and dressed, at approximately 10:06 am AV was seen in common area and given mask to wear, at approximately 10:20 am kitchen staff reported seeing AV walk down the driveway, at approximately 12:00 pm two staff made inquiries about if AV had been seen, and staff replied. "No, I haven't. I just got here." No further report given to any other staff or floor nurse until approximately after 2:00 pm. Administrator notified via phone of AV not seen at approximately 2:57 pm and LEA notified at approximately 3:37pm. On or about September 23, 2024, K9 team found AV at approximately 12:00 pm on the side of the highway in thick blackberry bushes. AV was transported to the hospital and admitted. AV was diagnosed with extensive abrasion to AV's face. arms and legs; acute kidney injury with rhabdomyolysis, secondary to dehydration; and acute metabolic encephalopathy representing delirium that resolved during hospitalization. AV was discharged from the hospital on October 3, 2024. The facility failed to provide a safe environment, failed to plan and implement safety checks on AV when AV level of care required an increase in reminders to find AV's apartment dining room and activity location as noted in AV's service plan dated Aust 29, 2024. The facility failure is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00280 $1125.00 fine assessed