- Date
- 12/21/2024
- Report number
- 00373684-AP-324082
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a history of falls. AV was admitted to the hospital on or around November 30, 2024, for fall and was discharged directly to facility on December 20, 2024. AV's pre-admission assessment was completed on or about December 18, 2024. On or about December 21, 2024, AV had an unwitnessed fall getting off the toilet and was found on the floor by staff. AV had a bump on AV's back as a result of AV's fall and rated pain 7 out of 10. AV's walker was found outside of AV's restroom in front of the bathroom door. On or about December 22, 2024, AV was not responding normal, was lethargic, and pale in color. EMS was called and transported AV to the hospital. On or about December 23, 2024, AV was diagnosed with a L2 transverse fracture and a soft tissue hematoma.
AV is service planned for being at high risk for falls with interventions such as reminding resident to use call light, safety checks, and ensuring AV's bed is in lowest position while AV is in bed. AV's service plan does not identify AV's ability to use call light, does not address toileting or AV transferring on/off toilet although AV is identified as being a 1-person transfer, and 1 person toileting assist in pre-admission assessment. AV's service plan does address AV's ambulation needs for stand by cueing that is noted in AV's pre-admission assessment. AV's service plan does not reflect AV's care needs that were identified in AV's pre-admission assessment related to transfers, ambulation, and toileting, The facility failed to appropriately care plan and implement reasonable interventions, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00894 $500.00 fine assessed