- Date
- 9/12/2024
- Report number
- 00364452-AP-314693
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- 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) known fall history. The AV experienced approximately three injury falls between September 12, 2024, through November 03, 2024. On or about November 03, 2024, the AV experienced a ground level injury fall causing severe pain to their leg. On November 04, 2024, the AV was unable to bear weight on their leg and was sent to the hospital. The AV returned from the hospital later on the same day with no diagnosis of injury. On November 05, 2024, the AV was still complaining of severe pain and was subsequently sent back to the hospital. The AV was then diagnosed with a fractured fibula. The AV experienced a significant change of condition and was admitted to hospice care. the AV was not able to return to their baseline level of care after this fall with injury. After each of the three injury falls, there was no documented evidence the AV’s service plan was updated with progressive, appropriate interventions to mitigate their falls, which resulted in a fall with injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00150 $1500.00 fine assessed