Violation Details: 00171913-AP-136469

Records Request Print
Date
11/23/2021
Report number
00171913-AP-136469
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) was a known fall risk. AV suffered 6 falls within 4 weeks. On or about November 19, 2021, AV returned from the hospital where he/she was being evaluated for chest pain. Upon AV's return, he/she was weak and tired and he/she was being treated for a urinary tract infection. No new fall prevention interventions were added to AV's care plan. AV fell three times after November 19, 2021, and when AV fell on November 23, 2021, AV fractured his/her scapula. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.