Violation Details: 00448560-AP-400562

Records Request Print
Date
11/21/2025
Report number
00448560-AP-400562
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to intervene when resident's condition changed
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), 411-054-0045(1)(b) and (f)(A) and (C)
Findings
The Alleged Victim (AV) resided at the facility and relies on staff for some assistance with activities of daily living. According to an investigation, on or about November 21, 2025, AV had a fall resulting in a fractured finger and wrist. AV was assessed at the hospital and returned to the facility wearing a brace. The after-care documentation provided to the facility instructed staff to make an appointment for AV with an orthopedic doctor within 5 days. In the days following the fractures, AV was not assessed by a facility RN and there was no orthopedic follow-up done. On December 28, 2025, AV complained of severe pain to the elbow area of the affected arm and was set to the hospital, resulting in diagnosis of open wound with exposed hardware of the elbow. There was no documented evidence the facility had assessed AV or provided monitoring of the change in condition following the fall with fractures in November. The facility failed to provide oversight and monitoring of a change of condition, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP26-00490 $500.00 fine assessed