Violation Details: 00138704-AP-109157

Date
5/7/2021
Report number
00138704-AP-109157
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
Result
Substantiated
Findings
On or about May 5, 2021, at 5:00 am, the Alleged Victim (AV) suffered a fall in his/her room. Emergency Technicians were called, however, AV refused to go to the hospital after this fall. The facility's call light system was not working, so staff were to check on all residents every 15 minutes to ensure safety. Later that evening, AV fell again and was found in his/her room approximately 9:00 pm after the fall. It is unknown how long AV was on the floor after the fall, as no one had checked on AV since 8:00 pm. AV was sent to the hospital and diagnosed with a brain bleed requiring surgery. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP21-01690 $500.00 fine assessed