Violation Details: 00410797-AP-361901

Records Request Print
Date
6/24/2025
Report number
00410797-AP-361901
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)
External site: 411-054-0027(1)(g) and (s)
External site: 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 is known not to use AV’s call light and is care planned for one-person assist for transfers. According to an investigation, on or about, between April 1, 2025, and June 12, 2025, AV experienced approximately fourteen falls. On or about, June 24, 2025, AV was found with bruising on their shoulder. On or about June 27, 2025, the bruising worsened, and AV was sent to the ER. AV was diagnosed with a fracture of the left clavicle. The facility failed to implement interventions to mitigate the risk of injury due to AV's increase in falls. This failure is a violation of resident rights, is neglect of care which constitutes abuse.
Sanction
RCFCP25-01267 $1500.00 fine assessed