- Date
- 10/12/2019
- Report number
- 00053356-AP-037199
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The facility failed to provide service to Alleged Victim (AV). AV had a known hip injury and an abduction pillow and hip brace were to be used when being transferred or when his/her incontinence brief was to be changed. AV’s care needs were not addressed in his/her care plan regarding changing incontinence briefs with the hip brace and abduction pillow. Investigation revealed that AV had experienced several hip dislocations resulting in significant harm and unreasonable discomfort. It is unclear exactly how many hip dislocations AV experienced or the circumstances of the incidents due to lack of facility documentation. AV also experienced a number of skin issues that occurred when staff was providing incontinence care. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP20-00305 $500.00 fine assessed