- Date
- 12/2/2024
- Report number
- 00370566-AP-320849
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. AV has a history of falls. AVs care plan indicates high fall risk, difficulty communicating needs, requires standby assist with all ambulation, AV is known to move the motion detector and to put self on floor. Plan also indicates that AV requires a toileting schedule, but the schedule is not explained. On or about December 2. 2024, AV was found on the floor in h/h bathroom. On December 6, 2024, staff responded to motion sensor and found AV on the floor with complaints of rib pain. AV was assisted to the bathroom and returned to bed. On December 8, 2024, AV fell in the kitchen while staff were present. AV was diagnosed with fractures ribs. On December 11, 2024, AV rolled from bed and was found on the floor. It was discovered that AVs motion sensor had been moved and didn’t go off. The facility failed to appropriately care plan and implement reasonable person centered interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01226 $500.00 fine assessed