Violation Details: 00382624-AP-333090

Date
2/6/2025
Report number
00382624-AP-333090
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Findings
On or about February 7, 2025, the Alleged Victim (AV) suffered two unwitnessed falls. AV is a known falls risk with a history of falls. AV has service plan interventions which include to use a walker, have grip socks on, safety checks, room free from clutter and frequent toileting. On this date, AV returned from the hospital sedated. AV was not placed on increased safety checks or monitoring. No interventions were placed between the first and second fall. AV's walker was not present during either fall, and AV did not have grip socks on. The facility's failure to ensure oversight, follow the care plan and ensure interventions were in place is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-00535 $250.00 fine assessed