Violation Details: 00364189-AP-335267

Date
11/4/2024
Report number
00364189-AP-335267
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Findings
The Alleged Victim (AV) is a known fall risk and is care planned to have frequent safety checks, toileting care 6 times per shift, standby assist for transfers and have a pressure pad alarm in place while AV was in bed. On or about November 4, 2024, at approximately 1:20 am, another resident alerted staff that AV had fallen. AV suffered two abrasions to his/her back during the fall. AV's last safety check was performed at 12:00 am. AV's pressure pad alarm was not in place and did not alert staff to AV being up. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-00237 $375.00 fine assessed