- Date
- 8/1/2025
- Report number
- 00417941-AP-369265
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on AP1 for health, safety support, and assistance with care needs. AV service plan indicates AV is categorized as a low fall risk, ambulates independently without the use of assistive devices and is independent with transfers. It is noted by staff AV wears cargo shorts that have strings on them and a phone holder attached to the side, which have been observed to catch on chairs. On or about June 7, 2025, AV experienced a witnessed, non-injury fall while standing up from the dining room table. The fall occurred when the AV’s shorts became caught on the chair, causing the AV to fall onto their right knee. No interventions were implemented following this incident. Subsequently, on or about August 1, 2025 AV stood up quickly from a chair, the shorts became caught on the arm of the chair, resulting in a fall. As a result of this incident, the AV sustained two abrasions on the left elbow, measuring approximately 0.5 inches and 1 inch in length. The facility failed to revise the care plan or implement reasonable interventions to address the known risk of the AV’s clothing catching on furniture. This failure to act constitutes a violation of the AV’s rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01144 $375.00 fine assessed