- Date
- 5/3/2025
- Report number
- 00399294-AP-349997
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Witness 1 (W1) is frequently disoriented, even in familiar surroundings and requires supervision. W1 is known to wander and enter other residents’ rooms. Interventions in W1 service plan dated on or about February 28, 2025, include staff to be vigilant in monitoring W1's movements and redirect W1. Alleged Victim (AV) is known to have agitation towards other residents that enter AV's room. AV will become upset when other residents wander into AV's room. Interventions in AV's service plan dated on or about April 23, 2025, include when AV is spending time in AV's room, staff are to encourage AV to leave AV's door closed top prevent others from entering AV's room. On or about May 3, 2025, AV reported to staff, while AV was in h/h room W1 wandered in and hit AV several times in the arm. AV was able to get W1 to leave AV's room. AV sustained bruising to h/h arm. A Temporary Service Plan (TSP) was put into place, instructing staff to monitor W1 trying to enter AV's room. On or about May 4, 2025, AV was in bed sleeping, and W1 was wandering the unit. Staff heard screaming from AV's room, W1 entered AV's room and hit AV, resulting in a skin tear to AV arm, and AV becoming upset. The facility failed to follow W1 service plan interventions to be vigilant of W1 movements, and redirection, and failed to follow the TSP instructing staff to monitor W1 trying to enter AV's room which resulted in an unsafe environment, and injury to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01097 $375.00 fine assessed