- Date
- 6/20/2024
- Report number
- 00357660-AP-308151
- 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, remind AV to call for assistance, and a bed cane will be placed near AV's bed. AV experienced an unwitnessed fall on or about May 29, 2024, two unwitnessed falls on or about June 6, 2024, resulting in AV hitting h/h head and being transported to the emergency room (ER) and diagnosed with a contusion to h/h forehead . AV experienced an unwitnessed fall on or about June 19, 2024, when AV was found on the flour attempting to ask for help. Fall intervention put in place, check at routine intervals at night without waking. AV experienced two more falls on or about June 20, 2024, sustaining bruising to h/h upper back in the first fall and a lump to h/h head in the second fall. AV was transported to the ER and diagnosed with a scalp hematoma. The fall prevention intervention listed after AV's fall on June 19, 2024 was not a new intervention as safety checks multiple times per shift was already listed in AV's Service Plan, dated May 21, 2024. 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