Violation Details: 00231790-AP-189608

Date
11/14/2022
Report number
00231790-AP-189608
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide service
Result
Substantiated
Findings
According to investigation and interviews, on or about November 14, 2022, AV experienced an unwitnessed fall while showering. AV was found crying, in severe pain, unable to put pressure on h/h left hip and stating that h/h hip was broken. AV was initially assessed on the floor for head injury, and then picked up and placed in four-wheel walker, pushed across the room, and transferred to h/h bed resulting in pain and unreasonable discomfort. The facility failed to have policy, procedures, and training to reflect best practices when there is a fall with a resident in severe pain, causing additional pain to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00468 $188.00 fine assessed