- Date
- 5/27/2024
- Report number
- 00333398-AP-284462
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is a high fall risk, and has history of multiple falls, with several falls being in h/h room and bathroom. AV has a call pendant and has a history of taking it off. AV is service planned for a walker and is known not to use it. AV service plan dated on or around April 13, 2024, AV is able to self-ambulate using h/h walker and at times, AV will forget h/h walker and will walk around the community. If AV is found to not have h/h walker, staff are to ask AV to sit down and staff are to go get h/h walker. Fall interventions in place, remind AV to call for staff when s/he is feeling unsteady or unwell, lock brakes on hospital bed, and ensure AV has proper footwear on; AV has slippers and will keep them at h/h bed side and put them on when getting out of bed. AV is independent in all toileting tasks. On or about May 26, 2024, AV fell trying to get to the bathroom. AV reported falling over the boxes that were blocking the walkway to bathroom. On May 27, 2024, AV fell at the threshold (carpet to linoleum) while attempting to ambulate to the bathroom by themselves resulting in a fractured arm. AV stated that s/he did not bring h/h pendant to the bathroom and was unable to ambulate back to the bed to use the pendant and stated that s/he was on the floor for approximately 2 hours. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP25-00120 $1125.00 fine assessed