- Date
- 2/4/2024
- Report number
- 00311155-AP-263689
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about February 4, 2024, Alleged Victim (AV) pressed his/her call light seeking assistance with his/her Activities of Daily Living. Based on facility documentation and interviews, AV waited 40 minutes after using AV's call light before AV attempted to self-transfer to use the restroom, resulting in AV falling, being transported to the hospital for treatment, and was diagnosed with a fractured hip. Due to AV's age, he/she was not a candidate for surgery due to risk, was placed on hospice, and passed away on February 10, 2024. At time of incident, the facility was operating short-staffed and received many requests for assistance from other residents that required two caregivers. The facility's call system was not set up to let caregivers know who was waiting, or who called for assistance first. Due to facility being short staffed, the facility failed to meet AV's scheduled and unscheduled care needs. The failure resulted in AV’s condition worsening causing further unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP24-00728 $1500.00 fine assessed