- Date
- 12/23/2024
- Report number
- 00374145-AP-324523
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victims (AV) resides in a locked memory care unit, and depends on the facility for AV needs, and safety. AV's Service plan dated on or about October 8, 2024, indicates AV has glasses, has poor peripheral vision downwards, AV cannot see downwards and will regularly look down at the ground while AV walks to see where AV is going. AV uses assistive device, walker. AV can ambulate and transfer independently with use of four-wheel walker. If staff see AV without AV's walker, staff to assist AV to sit down and encourage the use of AV's Walker. During investigation AV had a prior fall on or about November 30, 2024, and AV's service plan was not updated after this fall. On or about December 23, 2024, Staff observed AV in the dining room. AV stood up from the table with glass in h/h hand, was looking around for something to grab, took a step and fell to the ground landing on AV's right side. AV did not have h/h walker nearby when AV fell. AV was transported to the hospital for evaluation, diagnosed with a proximal right femur fracture, and had surgical intervention. AVs death certificate indicates Date of death December 27, 2024, A. Immediate cause of death acute blood loss anemia. B. Due to or as a consequence of Right intertrochanteric femur fracture. c. Due to severe dementia without behavioral disturbance. The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas: mobility/ambulation; fall risk has conflicting information which contributed to AV's fall in the dining room while staff observed the fall. The facility failed to provide a safe environment and failed to appropriately care plan and implement reasonable interventions, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00903 $2500.00 fine assessed