- Date
- 9/22/2024
- Report number
- 00363722-AP-314014
- 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 seizures and recurring falls. AV's service plan dated on or about July 2, 2024, indicates AV is a 2-person transfer, is ambulatory and loves moving around and going for walks and dancing. On or about September 14, 2024, AV had a seizure and fell, resulting in blunt head trauma, a forehead laceration requiring staples and a cut on the inside of h/h mouth. No additional interventions were put into place after this incident. On or about September 22, 2024, AV fell from a standing position resulting in AV being sent to the hospital and diagnosed with blunt head trauma, and two fractured fingers. Intervention put in place frequent checks, make sure AV uses toilet frequently. AV had two additional falls on September 23, 2024, and it is noted AV has been a lot weaker and not stable on h/h feet without assistance. Interventions to keep AV in areas where AV can be checked on frequently, complete safety checks at beginning end and least six times between. AV was found on the ground by h/h bed on or about September 29, 2024. It is noted AV has a change in mobility status, intervention put in place motion pad brought in by family. On or about October 01, 2024, AV was found on the ground next to the bathroom. Interventions put into place, staff to check 4x a shift to ensure AV is in h/h wheelchair. On or about October 5, 2024, AV was found on the ground in front of h/h wheelchair. The wheelchair had the footrest on at the time of incident. AV had 6 falls between September 14, 2024 to October 5, 2024, AV was 2-person transfer prior to the falls, interventions put into place after AV falls, 1-person assist with gait belt, and with ambulation staff to walk right next to h/h and hold h/h hand or arm to help provide some support, and if not walking safely encourage to sit in wheelchair, chair or bed. Complete frequent safety checks, and a motion mat was ordered however it does not indicate if this motion mat was implemented, as AV had several falls after with no mention of alarm notification, or if motion mat was in place. The facility failed to provide a safe environment, appropriately care plan and implement reasonable interventions to address AV’s ongoing falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00233 $1500.00 fine assessed