Violation Details: 00410935-AP-362057

Records Request Print
Date
6/29/2025
Report number
00410935-AP-362057
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
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) is care planned to have one to one care during the hours of 2:00 PM to 10:00 PM, due to sun downing, as an intervention for AV's behaviors and fall risk. On or about June 29, 2025, AV was placed into bed too early, approximately 7:00 pm, when AV's typical bed time is 9:00 PM to 10:00 PM. AV did not have a one to one caregiver, as outlined in his/her service plan. On this date, AV suffered a fall and was found on the floor on his/her buttocks. AV was not harmed, however, AV was placed at risk for harm. The facility's failure to follow AV's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-01091 $375.00 fine assessed