Violation Details: 00268739-AP-223651

Date
6/13/2023
Report number
00268739-AP-223651
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
Alleged Victim (AV) was care planned to be independent to self-transfer, per the April 26, 2023, care plan. On or about June 13, 2023, AV had an unwitnessed fall, AV was bending down to grab something out of a drawer and fell forward and then somehow backwards. As a result of the fall, AV sustained a broken bone to his/her right femur. AV needed to have surgery due to the broken femur. AV also had a fall on May 5, 2023, and had bruising on his/her shoulder and backside. There were no updates added to AV’s service plan to address the falls from May 5th and June 13, 2023. The facility failed to properly plan care and mitigate the risk of falls to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP24-01114 $1500.00 fine assessed