Violation Details: 00417280-AP-368646

Records Request Print
Date
7/16/2025
Report number
00417280-AP-368646
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
According to the documentation, the facility failed to follow the care plan for the Alleged Victim (AV) for transfer assistance which resulted in numerous falls. On or about June 20, 2025, and July 16, 2025, the AV suffered two falls, one on each day while trying to self-transfer. The service plan was updated after the fall on or about June 20, 2025, to offer bathroom assistance during safety checks. This intervention was not followed on or about July 16, 2025, when the AV attempted to self-transfer to the toilet and suffered a fall. The failure to follow the service plan for the AV to prevent future falls with injury is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-01297 $375.00 fine assessed