Violation Details: 00357126-AP-307845

Date
9/26/2024
Report number
00357126-AP-307845
Type
Abuse: Neglect
Level
4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation
Failed to properly plan care
Result
Substantiated
Findings
The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. On or about September 29, 2024, AV had an unwitnessed fall in his/her room. AV was found lying on the floor on his/her back in front of AV's dresser. AV was transported to the hospital for treatment, and was diagnosed with a hematoma with bleeding in the brain. Based on facility documentation and interviews, AV moved into the facility on August 22, 2024, and had six falls between August 22, 2024, and September 26, 2024; two of the six falls during this time period resulted in injury. The facility's failure to properly care plan for AV's known fall risk, caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-00095 $375.00 fine assessed