Violation Details: 00323723-AP-275308

Records Request Print
Date
3/15/2024
Report number
00323723-AP-275308
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(A) and (H)
External site: 411-054-0036(2)(g)
Findings
AV is a high fall risk and has a history of falls. AV had falls on March 02, 2024, March 03, 2024, March 04, 2024, 2 falls on March 05, 2024, and a fall on March 14, 2024. AV's fall on March 02, 2024, resulted in a fractured left shoulder and the fall on March 14, 2024 resulted in a compression fracture in the spine. AV's care plan at the time of the falls indicated AV is independent with ambulation, uses a 4 wheel walker, AV is independent with transfers and remind AV to lock wheels on walker when not ambulating. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which resulted in AV fracturing left shoulder, hitting h/h head, and a compression fracture in h/h spine, which is violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP24-00805 $1125.00 fine assessed