Violation Details: 00364216-AP-314474

Records Request Print
Date
11/3/2024
Report number
00364216-AP-314474
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide service
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0040(1) and (2)
Findings
The Alleged Victim (AV) relies on the facility for care and is a known fall risk. On or about November 2, 2024, AV went to the hospital for abdominal pain and it was discovered AV had a compression fracture of the first lumbar vertebrae, that was new since April 2024, when AV had a fall and imaging that showed no fractures at that time. According to an investigation, AV had approximately seven (7) falls between March 6, 2024 and September 3, 3034, with no change of condition documented with AV's mobility changes and increase in AVs pain. The facility failed to provide services, to include implementing interventions and or care planning to mitigate AV’s increasing fall risk, change of condition and monitoring, and resident safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-01358 $1125.00 fine assessed