- Date
- 8/14/2023
- Report number
- 00385897-AP-336426
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) lives in a locked memory care unit and relies on the facility for h/h needs and safety. AV service plan dated on or about June 19, 2023, indicates AV has poor memory, requires staff escort dinning for meals, has poor gait, uses an assistive device (AD) (cane, walker), needs reminders to use AD, and staff to ensure walker is within reach. AV is a two-person transfer, and two people assist to standing position. AV has a fall history, with interventions in place. Staff to check on AV no less than 4 times a shift, encourage AV to use walker instead of can when weak and tired, Keep AV's room free from clutter. On or about August 14, 2023, was walking in the community area without h/h walker and tripped on another resident’s walker and fell. AV his h/h head sustained a black eye and bruise to the left forearm. The facility failed to follow AV's care plan resulting in a fall resulting in injury and pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00983 $500.00 fine assessed