Violation Details: 00313820-AP-266161

Records Request Print Provider Details
Date
2/16/2024
Report number
00313820-AP-266161
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a recent history of falls. According to an investigation, on or about February 16, 2024, AV was found on the floor in their apartment with a wound to the back of the head. AV had a fall previously on February 6, 2024. AV's service planned interventions were for staff to provide stand by assistance for all transfers and to provide physical assistance with ambulation on a regular basis. Facility staff were aware AV did not like using a call light. The facility did not develop or implement changes to AV's care plan following the fall on February 6, 2024, or provide new interventions to address AV’s fall risk, resulting in another fall with injury. The facility failed to properly care plan for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
ALFCP26-00078 $188.00 fine assessed