- Date
- 9/15/2023
- Report number
- 00385897-AP-336425
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is a resident of the facility and relies on facility staff to ensure AV's personal cares, safety, and supervision requirements are met. AV has a known, all history. Per AV care plan, AV has a poor gait and needs reminders to use AV's assistive devices , staff are to check on AV 4-times per day to see if AV needs toileting assistance, staff are to check on AV no less than 4 times per shift, staff are to ensure AV's blankets are tucked into AV's bed to prevent AV from falling. AV did not always remember to use AVs call pendant. On or about September 15, 2023, AV fell in AV's room, sustaining a skin tear to AV's right arm. AV fell when attempting to self-transfer out of AV's bed to get to the bathroom and tripped over the sheet that was dangling off the bed. The facility to follow AV's care plan, which led to AV falling and sustaining injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00983 $500.00 fine assessed