Violation Details: 00419566-AP-370946

Records Request Print
Date
8/9/2025
Report number
00419566-AP-370946
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
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: 411-05400030(1)(e)(I), 411-054-0036(2)(b) and (g),
Findings
The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of exit seeking and elopement from the secured unit. According to an investigation, on or about August 9, 2025, AV was noticed to be missing and was found on or about an hour and a half later at a grocery store. AV's service plan identified signs of the exit seeking behavior and directed staff to offer to go walking with AV around the community and courtyards, invite AV to assist with tasks and to perform hourly checks. Staff were aware AV would often try to leave the secured unit when visitors entered or exited. The facility failed to develop interventions to ensure AV's service planned need for supervision. The facilities failure to properly plan care resulted in potential risk of serious harm for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
RCFCP25-01329 $500.00 fine assessed