- Date
- 5/17/2024
- Report number
- 00332877-AP-284058
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim’s (AV’s) care plan states that AV does not require assistance with transfer or ambulation. On or about April 20, 2024, AV sustained a fall from his/her bed. On or about May 16, 2024, AV’s hospice ordered a hospital bed for AV, with a delivery date of May 23, 2024, due to AV’s declining health. The facility was informed of AV’s decline in health and his/her change in ambulation. On or about May 18, 2024, AV slipped out of his/her bed while AV was trying to stand up and fell to the floor. On or about May 20, 2024, staff found AV face down on the floor of AV’s bedroom up against AV’s metal bed frame. As a result, AV sustained a skin injury due to the fall. If the facility has a fall incident, the facility will complete an occurrence report, alert charting, and complete a temporary care plan (TCP), however, no TCPs were provided by the facility that documented AV’s fall incidents from May 18th and 20th, 2024. The facility failed to properly plan care around AV’s known changed in ambulation condition and by not properly following up with a TCP, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP24-00832 $250.00 fine assessed