- Date
- 1/22/2023
- Report number
- 00243436-AP-199908
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The facility failed to implement interventions and follow the Alleged Victim’s (AV) care plan regarding AVs known fall risk. AVs care plan states for staff to clear AVs room of trip hazards. On or about December 4, 2022, AV had a fall that resulted in a head injury. The facility did not add interventions and update AVs care plan after that fall. On or about January 22, 2023, staff brought AV breakfast and left AVs apartment. On the way to get to the food, AV tripped over a rug in his/her apartment, resulting in a fractured wrist, hip, and nose and orbital bruising. AV was transferred to the hospital for treatment, which included surgery. The facility failed to follow AVs care plan to remove trip hazards from the room and implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP23-00513 $2500.00 fine assessed