- Date
- 5/30/2025
- Report number
- 00406061-AP-357110
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- According to the documentation, the facility failed to care plan appropriate interventions to prevent the Alleged Victim (AV) from falling. On or about May 27, 2025, the AV attempted to self-transfer out of their wheelchair, resulting in a non-injury fall. A temporary service plan (TSP) was created to instruct staff to have eyes on the AV at all times. The staff confirmed this TSP was not able to be followed due to staff needing to step away to assist other residents. on or about May 30, 2025, the AV experienced an unwitnessed fall. The facility failed to care plan appropriate interventions to prevent the AV’s known history of falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00981 $375.00 fine assessed