- Date
- 11/16/2022
- Report number
- 00232348-AP-190151
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to perform adequate screening or assessment
- Result
- Substantiated
- Findings
- The facility failed to perform adequate assessments, implement interventions and appropriately care plan related to the Alleged Victim’s (AV) history of falls, several requiring emergency services. On or about October 17, 2022, AV’s service plan noted a change of condition due to increase in falls, though no meaningful interventions were placed to mitigate the risk of falls or injury. On or about November 15, 2022, AV returned from the hospital, after experiencing an unwitnessed fall with injury to his/her head and skin with no changes in instruction. On or about November 16, 2022, AV was found on the floor, following an unwitnessed fall, unresponsive, had sustained a head injury, and passed away. The facility’s failures are a violation of resident rights, are considered neglect of care and constitute abuse.
- Sanction
- ALFCP23-00210 $2500.00 fine assessed