Violation Details: 00077247-AP-057082

Date
3/25/2020
Report number
00077247-AP-057082
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to assure timely medical treatment
Result
Substantiated
Findings
According to documentation, On or about March 25, 2020, the Alleged Victim (AV) did not have a service plan available, or parameters regarding safety checks, though s/he was a known fall risk. At approximately 11:48 am, AV used his/her pendant to call for assistance and care staff were unaware, due to an error in the system and a shortage in staffing. AV was discovered approximately 30 minutes later, by a staff member delivering his/her food tray. His/her lips and finger tips were blue, had a low oxygen level, and the pendant clip had penetrated one of his/her fingers. The facility's failures placed AV at risk of serious harm, and delayed necessary medical treatment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP20-00784 $375.00 fine assessed