- Date
- 5/1/2025
- Report number
- 00399139-AP-349868
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is known to exhibit wandering behaviors. Witness 1 (W1) has a known history of becoming aggressive when other residents enter W1’s personal space. According to AV’s service plan, dated on or about March 31, 2025, AV has a pattern of entering other residents’ rooms. AV's plan directs staff to redirect AV and offer an activity, it also indicates velcro door guard placed against W1's room to prevent residents from entering W1's room. W1’s service plan, dated on or about April 24, 2025, does not include specific interventions for situations in which other residents enter W1’s personal space. The plan also does not mention the use of signage to discourage entry into W1’s room. On or about May 1, 2025, AV wandered into W1’s room, resulting in a resident-to-resident altercation. W1 yelled at AV and struck AV, causing visible redness to AV’s arm. AP1 failed to follow AV’s service plan by not redirecting AV when AV was observed wandering. Additionally, AP1 did not adequately care plan or implement appropriate interventions to address W1’s known behavioral responses to residents entering into W1's personal space. These failures directly contributed to the altercation and resulted in physical harm to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01295 $375.00 fine assessed