Violation Details: 00298420-AP-251999

Date
11/26/2023
Report number
00298420-AP-251999
Type
Abuse: Neglect
Level
4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation
Failed to properly plan care
Result
Substantiated
Findings
According to the documentation, the facility failed to provide interventions to assist the Alleged Victim (AV) for their known history of depression. On or about November 08, 2023, the facility conducted a new move in assessment and identified the AV had situational depression due to their current status. On or about November 15, 2023, the AV moved into the facility. Approximately eight days later on November 23, 2023, the AV made comments to staff stating they didn’t want to live anymore. The AV allegedly infrequently made these comments while in independent living. The staff members who the AV told they didn’t want to live anymore did not report these comments to administrative staff or nurse. On or about November 26, 2023, the AV was found on the floor in their shower with three self-inflicted stab wounds to the chest. The AV was pronounced deceased at the scene. The facility failed to provide interventions to assist the AV with their known history of depression and suicidal comments, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP25-00085 $2500.00 fine assessed