- Date
- 6/6/2024
- Report number
- 00357660-AP-308150
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on facility staff to ensure h/h basic care, safety, and supervision requirements are met. AV service plan dated on or about May 21, 2024, indicates AV is independent with ambulation and transfers, independent using a walker, and requires staff to provide assistance each shift with toileting and as needed or requested by AV. AV often wakes in the night to use the restroom. AV is able to use h/h call light independently. Fall interventions in place, ensure AV is using h/h walker, safety checks three times per shift, sign placed in AV’s room reminding AV to sit before putting h/h shoes on, and reminding AV to call for assistance. AV experienced an unwitnessed fall on or about May 29, 2024, in h/h room; the fall prevention interventions implemented after the fall was for a sign in AV's room reminding AV to sit before putting on h/h shoes to be "replaced" and AV safety check times were clarified to be at the beginning and end of each shift, mealtimes, and medication passes. AV experienced two unwitnessed falls on or about June 6, 2024, resulting in AV hitting h/h head and being transported to the emergency room (ER) due to being more confused than normal and being on anticoagulant medication. At the ER, AV was diagnosed with a contusion to h/h forehead and a urinary tract infection. The fall prevention interventions implemented after AV's fall on May 29, 2024, were not new and were interventions already in place in AV's service plan dated May 21, 2024, and the intervention noted after AV's first fall on the morning of June 6, 2024, had not yet been implemented when AV fell the second time resulting in a contusion to h/h forehead. The facility failed to appropriately care plan and implement reasonable person-centered interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00255 $1500.00 fine assessed