- Date
- 1/3/2025
- Report number
- 00375212-AP-325652
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV and Witness 1 (W1) have a history of resident-to-resident altercations, but not with each other. W1 Service Plan dated on or about December 20, 2024. W1 is services planned for behaviors triggered by other residents walking into W1's room, Interventions: Velcro sign on W1's door to prevent residents from entering W1's room. AV Service Plan dated on or about December 21, 2024, AV may become physically aggressive when others enter residents room. Interventions: If staff notice another resident walking into AV's room, staff are to redirect that resident away from AV's room. On or about January 3, 2025, AV wandered into W1's room. AV and W1 had an unwitnessed resident to resident altercation in doorway of W1's room, staff report hearing resident commotion and when approached saw W1 on the ground and AV standing over W1 with AV's hands in a fist. W1 complained of head pain, visible scratch/bruising to (L) eye. AV complained of chest pain and (L) eye blackened. AV was last seen by staff in AV's room approximately 30 minutes before the altercation. W1 was seen by staff walking towards W1's room a few minutes before the altercation. The facility failed to provide a safe environment, and failed to properly plan care around AV and W1 history of resident-to-resident altercations, and the facility has identified W1's behavioral trigger but has not provided adequate person centered interventions to prevent other residents from entering W1's room.
- Sanction
- RCFCP25-00415 $375.00 fine assessed