Violation Details: 00383906-AP-334703

Date
2/16/2025
Report number
00383906-AP-334703
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Findings
According to the documentation, the facility failed to follow the care plan for Witness 1’s (W1) known behaviors resulting in resident-to-resident altercations. W1 was care planned to have a 1:1 care giver due to their history of resident-to-resident altercations. On or about February 16, 2025, W1’s 1:1 caregiver stepped away from W1 to help a community member but kept W1 in line of sight. W1 then got up from the table and engaged in an altercation with the Alleged Victim (AV) pushing them down and causing them to hit their head. The AV’s head was swollen, and the next day had bruising to their head. The facility failed to ensure the service plan for W1 was being followed, resulting in an altercation and the AV to suffer pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-00606 $375.00 fine assessed