- Date
- 9/18/2022
- Report number
- 00224498-AP-183012
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is known to be a fall risk due to weakness and cannot ambulate long distances. Staff are to provide support with transfer and provide frequent safety checks, at least four times per shift. On or about September 18, 2022, at about 5:30am, AV’s neighbor informed staff that he/she had been hearing a person crying and yelling for hours and it had woken them up. NOC caregivers were asked to assist day shift in finding where the yelling was coming from. Staff found AV on the floor in their living room with his/her head under the desk. AV was pulled from under the desk and was found to have blood on their sweater. No night checks were being done, AV was last checked on at around 10:40pm and then no one checked on AV until 5:45am. There is a list of who is to be checked every two (2) hours, but staff are not documenting when the resident gets checked to assure the two (2) hours checks are occurring. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3), failed to provide a safe environment for AV which resulted in injury, and which is neglect of care and constitutes abuse. On or about October 2022, AV’s antibiotic medication was missed a total of 12 times in a 5-day period. On or about September 2022, there were 120 missed medications, reasons stated is AV refused and medications not arrived for 22 of those passes. The facility failed to provide service for AV relating to properly assuring checks on AV were being conducted and documenting and by failing to provide a safe medication system, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP23-00692 $250.00 fine assessed