- Date
- 11/7/2024
- Report number
- 00366079-AP-316326
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- According to the documentation, the facility failed to implement appropriate fall interventions for the Alleged Victim’s (AV) known fall history. Alleged Perpetrator 2 (AP2) failed to provide assistance to the (AV) after they were seen on the floor with blood on their face. On or about November 07, 2024, the AP2 was passing medication and found the AV on the floor, their legs in the air and blood on their face drinking a beverage. The AP2 continued to pass medications and returned a few minutes later to aid the AV. Upon evaluation, the facility staff determined the AV needed medical attention and sent the AV to the ER. The AP2 failed to provide aid to the AV immediately when they found them on the floor, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Review of the Av’s service plan showed interventions to prevent falls that was not appropriate for the AV. The facility failed to update the AV’s care plan with appropriate fall interventions for AV’s history of injury falls. The failure resulted in the AV experiencing a fall and sustaining a head injury which needed to be assessed at the hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00152 $1125.00 fine assessed