- Date
- 10/13/2024
- Report number
- 00360361-AP-310682
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim’s (AV) high fall risk resulting in falls and multiple fractures. On or about September 26, 2024, the AV moved into the facility with a known history of falls. The initial care plan for the AV noted the AV as a high fall risk. On or about October 03, 2024, the AV was found on the floor and upon examination, experienced no injuries from the fall. Approximately ten days later, on October 13, 2024, the AV experienced an unwitnessed fall and was found to have a skin tear and complained about pain in their ribs. Family was notified and told the facility not to send to the hospital as they would make an appointment the following day. On or about October 14, 2024, the AV was taken to the ER and was diagnosed with a skin tear, fractured ribs and a fractured vertebrae in their back. The failure to update the AV’s care plan with appropriate fall interventions for the AV’s known fall risk and history of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00099 $0.00 fine assessed