- Date
- 5/2/2025
- Report number
- 00399164-AP-350128
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) and Witness 1 (W1) both rely on facility staff for their health and safety. W1 has a diagnosis of dementia and exhibited agitation and combative behavior prior to admission. On or about April 27, 2025, staff noted W1 wandered frequently, entered other residents’ rooms, and interacted briefly before leaving. Staff were instructed to monitor W1. On or about May 2, 2025, a series of events took place with W1. W1 was involved in an altercation after entering another resident’s room and taking a hairbrush, resulting in W1 being struck with the hairbrush. Later that day, W1 became agitated during care. Staff stepped out to allow W1 to calm down and administered a PRN. W1’s care plan included redirection strategies such as discussing W1’s pet, calling W1’s spouse, or offering music or TV. Shortly after, Witness 6 (W6) heard a scream and found W1 in AV’s room. W1 was holding AV’s arm and then threw AV into a bedside table. AV sustained a bump on h/h head, shoulder pain, and reported fear of W1 hurting AV again. W1 has a pattern of aggressive behavior. The facility failed to implement effective, person-centered interventions, resulting in AV’s physical and emotional harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01095 $500.00 fine assessed