Violation Details: 00356929-AP-307403

Date
9/24/2024
Report number
00356929-AP-307403
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
The Alleged Victim (AV) has a known history of falls with injury. According to an investigation, on approximately September 24, 2024, the AV fell or was found on the floor three times, resulting in unreasonable discomfort and a fractured hip. There was no evidence fall interventions were implemented for the AV. Alleged Perpetrator 2 (AP2) instructed staff to assist the AV to a couch after the third fall without visually observing or conducting an evaluation of the AV. The AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility failed to appropriately care plan for the AVs known fall risk, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.
Sanction
RCFCP25-00909 $1125.00 fine assessed