- Date
- 9/17/2023
- Report number
- 00286143-AP-240393
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- On or about September 17, 2023, Alleged Victim (AV) fell from the second-floor balcony, was found on the ground, and suffered major injuries as a result of the fall. Based on interviews and facility documentation, AV has a history of suicidal ideations and has verbalized wanting to kill himself/herself and jump off the balcony. AV is care planned to receive two psychotropic medication and AV refused both psychotropic medications. AV had six crisis situations during the month of March 2023, and no-showed to three mental health assessment appointments on March 6, 2023, May 23, 2023, and August 17, 2023. AV was scheduled for three appointments by his/her mental health provider and no-showed to these appointments. The facility failed to arrange mental health appointments for AV, and failed to appropriately care plan for AV's resistance to psychotropic medication which left AV at risk of continued suicidal ideations. As result of AV falling from the second-floor balcony, AV shattered both heels and required back surgery due to injuring a couple of vertebras. The facility's failure to properly care plan for AV's suicidal ideation is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP24-00097 $1500.00 fine assessed