Violation Details: 00364260-AP-314500

Records Request Print
Date
10/27/2024
Report number
00364260-AP-314500
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0036(2)(g), 411-054-0040(1)(d)(A) and (B)
Findings
The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about October 27, 2024, AV fell while trying to self-transfer and on October 31, 2024, AV fell while slipping out of bed. AV's service planned interventions were for staff to remind AV to use a pull cord to call for assistance and wear non-slip socks. The facility did not develop or implement any known changes to AV's care plan following the falls. The facility failed to develop fall interventions to address AV’s fall risk, resulting in injury and a skin tear. The facility failed to properly plan care for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
RCFCP25-00366 $250.00 fine assessed