- Date
- 9/21/2024
- Report number
- 00356125-AP-306531
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) resides in a secured memory care unit and relies on the facility for his/her care. AV has a history of exit seeking behaviors and falls. Care planned behavior interventions were that AV required staff to provide redirection. The memory care unit has an elevator, and the door opens into the secured unit common area. According to an investigation, on or about September 21, 2024, AV entered the elevator without staff assistance. AV exited the elevator in an unsecured area of the building and fell down a stairwell, resulting in hospitalization and a fractured back. The facility failed to provide a safe environment, which is a violation of resident’s rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP24-01168 $500.00 fine assessed