- Date
- 11/6/2021
- Report number
- 00169018-AP-134771
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim's (AV's) service plan dated on or about September 1 2021 to November 17, 2021 indicates AV is a high fall risk with history of falls. AV uses a 4 wheeled walker for short distances and an electric scooter for longer distances. AV ambulates independently and is able to transfer independently from bed, but does take time to get balanced. AV can get in/out of reclining lift chair, on/off toilet, and in bed independently. AV needs help getting out of bed 3-4x/week due to morning weakness & hip pain. AV has unsteady gait, generalized weakness & edema in lower legs. AV fell on or about on or about September 22, 2021 and September 23, 2021, no interventions implemented after falls. On or about September 27, 2024 AV fell, resulting in a head injury. Intervention implemented offer toileting assistance after each meal. On October 9, 2021 AV had an unwitnessed fall, no interventions implemented. On or about November 6, 2021 AV had an unwitnessed fall. AV used AV's call pendant to call for help AV was sitting with AV's back against AV's bed. AV was unable to stand or walk, and was transported to the hospital. AV diagnosed with a broken tailbone. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.