- Date
- 12/6/2024
- Report number
- 00370390-AP-320795
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is a known fall risk with a history of falls occurring while trying to self-transfer from AV’s bed or recliner and attempting to retrieve his/her walker. AV is care planned for total assistance with ambulation and transfers. According to an investigation, on or about December 6, 2024, AV had an unwitnessed fall in his/her room while attempting to cross the room to retrieve his/her walker, which resulted in a head injury and skin tears to AV’s elbow and shin. It was discovered that no new interventions were added to AV’s care plan after the prior fall that occurred on or about November 11, 2024. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning and lack of appropriate interventions, to mitigate the risk of injury due to AV's increase in falls and failing to provide clear instruction to staff as to where to leave AV’s walker when AV was in bed and/or the recliner, which is a violation of resident rights, is neglect of care which constitutes abuse.
- Sanction
- RCFCP25-00039 $1125.00 fine assessed