Violation Details: 00418973-AP-370364

Records Request Print
Date
6/17/2025
Report number
00418973-AP-370364
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate 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) has cognitive deficits, fragile skin and relies on the facility for his/her care. AV's service planned interventions for falls were for two staff to assist with transfers and to remind AV to use the call cord when needing assistance. According to an investigation, on or about June 17, 2025, AV was observed to have two lacerations on their buttocks. The lacerations were determined to be caused when AV scooted down in their recliner and rubbed against metal parts in the footrests. AV has a history of attempting to self-transfer. AV's service plan did not have effective interventions to address the use of the recliner and reduce the risk of injury. The facility failed to properly care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse.
Sanction
RCFCP26-00116 $250.00 fine assessed