- Date
- 2/8/2024
- Report number
- 00314172-AP-266451
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On February 7, 2024, Alleged Victim (AV) experienced a fall resulting in AV hitting his/her head. AV was admitted to the hospital after the fall and diagnosed with facial injuries, an intracranial hemorrhage, a right periorbital ecchymosis, and bleeding from the lip. Based on facility documentation and interviews, all responsible caregivers were in the laundry room at time of incident. The laundry room is about 30 yards away and is not a part of the locked unit where AV was at time of incident. There was no staff on the floor monitoring residents. There was no staff available to provide supportive services to prevent falls/harm to all residents. Based on AV's care plan, AV needs to be escorted during ambulation to prevent falls and staff are advised to monitor AV closely. Prior to incident, AV was put to bed shortly after being showered but showed signs of agitation, so staff put AV's shoes anticipating movement. However, AV was not monitored closely, allowing AV to get out of bed without staff knowledge which resulted in the fall. The facility failed to provide basic care and adequate supervision to AV which resulted in a fall causing serious physical harm and unreasonable discomfort to AV. When AV was discharged from the hospital, AV was placed on comfort measures. The facility's failure to provide a safe environment for AV is a violation of resident rights, is considered neglect of care, which constitutes abuse.
- Sanction
- ALFCP24-00733 $1500.00 fine assessed