- Date
- 9/18/2025
- Report number
- 00427829-AP-379513
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is a known fall risk and has suffered repeated falls. Although AV's service plan diagnosis section notes that AV has repeated falls, AV's service plan did not contain a fall risk section. On or about September 18, 2025, AV was found in his/her room on the floor at 4:30 am. Staff placed AV back into his/her wheelchair and determined no injury to AV from this fall. After this fall, the facility completed a temporary service plan (TSP) with interventions to decrease AV's falls, however, day shift staff had not reviewed AV's TSP that had been produced earlier that morning. At approximately 11:30 am the same day, AV was found in his/her room, asleep in his/her wheelchair with visible injuries to his/her head and right elbow. AV was transferred to the emergency room where he/she was diagnosed with a fractured tailbone, a fractured collar bone and a brain bleed.
- Sanction
- RCFCP25-01456 $1125.00 fine assessed