Violation Details: 00241862-AP-198505

Date
1/15/2023
Report number
00241862-AP-198505
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Findings
Alleged Victim’s (AVs) service plan dated December 30, 2022, indicates AV has decreased mobility and requires staff to use a gait belt and provide standby assistance and a walker when ambulating. According to interviews and documentation AV fell on January 10, 2023, when in his/her bathroom alone and again on January 11, 2023, in the common area. On or about January 15, 2023, AV was discovered to have extreme difficulty ambulating, exhibiting signs of pain with every step while favoring their right leg and bruising on his/her left arm. AV was transported to the hospital and diagnosed with a left hip fracture. Camera review of night of January 14, 2023, shows AV sitting at dining room table, getting up, walking to bedroom without walker and without staff supervision or assistance. The facility repeatedly failed to follow the care plan and provide a safe environment, which is a violation of resident rights is neglect of care and constitutes abuse.
Sanction
ALFCP23-00385 $188.00 fine assessed