- Date
- 11/9/2025
- Report number
- 00439014-AP-390821
- 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) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about November 9, 2025, AV fell out of a wheelchair while seated in the common area, resulting in bruising and a shoulder injury. AV had been observed leaning over in wheelchair prior to the fall. AV's service planned interventions were for staff to monitor AV's location and for AV to be watched closely and assisted with transfers. AV's service plan included use of a pressure alarm on AV's wheelchair, fall mat and safety checks 4-6 times per shift. AV had three previous falls in October 2025 with no new interventions to address the fall risk or direction to staff. The service planned pressure alarm was not functioning at the time of the fall on 11/9/25. The facility failed to develop fall interventions after previous falls and failed to follow the care plan to provide supervision and an alarm, resulting in injury and bruising. The facility failed to properly plan care and follow the care plan for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- RCFCP26-00202 $250.00 fine assessed