- Date
- 8/20/2023
- Report number
- 00283889-AP-245055
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. AV’s Care Plan stated he/she is to have a 1-person assist with all transfer. On or about September 3, 2023, AV was found lying on his/her right side with his/her side of his/her face on the floor with a towel wrapped around. There was a Care Partner present with AV which was applying pressure to AV’s head until EMTs arrived. On or about August 20, 2023, AV was attempting to self-transfer from his/her recliner to their wheelchair. AV’s feet went out from under them, and the power had flickered from the wheelchair causing AV to fall. AV then used the pendant for help but staff were not notified. He/she was yelling from his/her room for help. On or about August 17, 2023, AV rang his/her pendant, and a staff called another staff member to come to AV’s room. AV was found on the floor in front of the dresser. AV stated his/her leg collapsed under him/her when he/she attempted to stand and transfer from the wheelchair to the recliner. The facility failed to follow the care plan around AV’s transfers, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP23-00723 $250.00 fine assessed