- Date
- 1/26/2025
- Report number
- 00380186-AP-330715
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has had 10+ falls between October 2024 and January 26, 2025. AV's service plan dated on or about January 13, 2025, notes AV is a low fall risk and should be checked on 2x per shift and staff are to assist AV into h/h recliner after meals. AV fell on or about December 14, 2024, Staff did not transfer AV into the recliner after the meal. Interventions noted are to again have staff assist AV to recliner after meals and place non-skid strips in front of recliner. Non-skid strips were not in the incident report and not added in front of AV's recliner by observation of investigator. AV fell on December 20, 2024, intervention was to ensure AV has shoes on. AV fell on December 21, 2024, AV was not wearing proper shoes. AV fell on January 4, 2025, and was sent to the ER due to pain in hip/ribs. No new interventions noted. AV fell on January 8, 2025, and had slippers on, not proper shoes. No new interventions noted. AV fell on January 26, 2025, and was sent to the ER with a wound above left eyebrow that was bleeding. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, and failed to follow interventions that were in place, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00890 $1500.00 fine assessed