Violation Details: 00231383-AP-189276

Records Request Print
Date
11/4/2022
Report number
00231383-AP-189276
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) had a known history of falls and was care planned for frequent checks. On or about November 4, 2022, AV was found on the ground in his/her room with a skin tear, his/her wrist hurt and he/she was confused. AV was sent to the hospital and was diagnosed with a broken wrist. After this fall, the facility put into place a change of condition and updated his/her care plan, however, did not put into place person specific interventions to anticipate AV's needs to reduce the risk of falls. AV suffered two additional falls, one with injury and one without. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00158 $250.00 fine assessed