- Date
- 3/5/2024
- Report number
- 00317099-AP-269461
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a history of falls and physical weakness. AV had a prior fall in July of 2023, AV sustained a fractured hip at the facility. Between December of 2023, and February of 2024, AV had at least three falls with injury, two of which AV was seen at the hospital. On or about January 25, 2024, AV was diagnosed with [low blood value] and the facility was informed that AV may experience light-headedness as a result. On or around February 28, 2024, and March 3, 2024, AV experienced episodes of high blood pressure which may contribute to feelings of dizziness. AV service plan dated on or around February 07, 2024, indicates AV has balance issues, takes medications affecting balance, and has diagnoses that would contribute to falls. Under Physical mobility, transferring: AV needs stand by assist with all ambulation to and from the dining room, is able to ambulate in h/h apartment independently and transfer independently. Under Fall prevention: Av needs stand by assistance when walking long distances, such as to and from the dining room. Staff to check with resident to make sure that footwear is on appropriately when in the room or ambulating with AV. Under toileting: AV needs assistance with transferring, once AV is in the bathroom AV is independent with all toiletings and will call for staff assistance. The service plan instructions to staff are not clear, as Under Physical mobility, transferring: AV is s able to ambulate in h/h apartment independently and transfer independently, but under under toileting: AV needs assistance with transferring, once AV is in the bathroom AV is independent with all toiletings and will call for staff assistance. On or about March 5, 2024 AV fell while bending over to get some toilet paper in a small cupboard in h/h bathroom hitting h/h head resulting in a knot on the back of h/h head and complained of left hip pain. AV was transported to the emergency room and diagnosed with a broken pelvis and left elbow. The facility failed to properly plan care and ensure proper interventions were in place to address AV's high risk of falls and have clear written direction for staff to follow.
- Sanction
- ALFCP24-00725 $375.00 fine assessed