Violation Details: 00162114-AP-128511

Date
9/26/2021
Report number
00162114-AP-128511
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
Alleged Victim (AV) relies on the facility for his/her care. AV wears an agency pendant instead of a facility pendant. AV has a history of falls and one of AV’s fall interventions includes his/her agency pendant and charging it, but does not include staff checking that AV is wearing it. AV was taken from the facility on September 23, 2021 by family, the pendant was removed for charging and not replaced by family. Family called the facility the next day and asked for them to place the pendant on AV. Staff forgot to place the pendant on AV. On or about September 26, 2021 AV was found on the floor at 8:00 am, it is unknown how long AV was on the floor. AV was taken to the hospital and diagnosed with a fractured hip. The facility failed to appropriately care plan to ensure AV is wearing his/her agency pendant, which is violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP21-03212 $375.00 fine assessed