- Date
- 5/21/2025
- Report number
- 00403044-AP-353973
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) has cognitive deficits, resides on a secured unit and relies on the facility for his/her care. AV has a history of exit seeking behavior, is known to be up at night and is care planned to be checked on every two to three hours from staff. Staff had been trained to keep doors in the kitchen area locked. According to an investigation, on or about May 21, 2025, AV was observed outside the building around 4:35 AM in 43 degree (Fahrenheit) temperatures with no shoes or socks on his/her feet. AV was outside for approximately 13 minutes, resulting a risk of serious harm and unreasonable discomfort to AV's hands and feet. On or around June 1, 2025, AV was found outside the building at 8:20 AM. The Alleged Perpetrator 2 (AP2) may have accidentally left a door unlocked. There was no alarm on the door or other means of notifying staff AV had left exited the facility. The facility failed to provide a safe environment, which is a violation of resident’s rights, is neglect of care and constitutes abuse. The allegation that the Alleged Perpetrator 2 (AP2) neglected the Alleged Victim (AV) was investigated and determined to be inconclusive.
- Sanction
- RCFCP25-01035 $375.00 fine assessed