Violation Details: 00243269-AP-199687

Records Request Print
Date
1/24/2023
Report number
00243269-AP-199687
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
On or about January 24, 2023, the facility failed to follow Alleged Victim's (AV) care plan which resulted in AV falling and hitting his/her head on the toilet during an attempted one-person assist during toileting. Based on facility documentation and interviews, AV is a two-person assist with gait belt with all transfers. The staff member who assisted with AV's transfer during toileting, was trained by other staff to do a one-person transfer when assisting AV with his/her care needs. The facility's failure to follow AV's care plan and properly train staff caused AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
ALFCP23-00469 $750.00 fine assessed