- Date
- 9/26/2024
- Report number
- 00357731-AP-308091
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a history of falls, AV has interventions in place with a transfer pole next to bed, lap buddy while in wheelchair, and pressure alarm in place under AV at all times while in wheelchair and in bed. On or about August 3, 2024, AV was found lying on the floor in the common area, initial assessment AV had no injuries, on August 4, 2024, AV complained of pain and transported to Emergency room. AV returned from the hospital with a diagnosis of fracture pelvic and sacrum and bruising to the right hand. Interventions in place at time of August 3, 2024, fall, focused on the use of a chair alarm and a lap tray, but the chair alarm did not sound, and the lap tray was reported to be broken. These interventions appeared to be ineffective, the facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00235 $1500.00 fine assessed