Violation Details: 00407829-AP-358859

Records Request Print
Date
6/14/2025
Report number
00407829-AP-358859
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility for his/her care and has a history of falls. AV's care planned fall interventions included use of a fall mat and keeping pathways clear. AV made complaints about the fall mat being in the way and asked for it to be removed. Witness 1 (W1) observed AV kicking the mat out of the way. According to an investigation, on or about June 14, 2025, AV fell after tripping over the mat, resulting in a femur fracture requiring hospitalization. The facility failed to properly plan care, which is a violation of resident’s rights, is neglect of care and constitutes abuse.
Sanction
RCFCP25-01303 $1125.00 fine assessed