Violation Details: 00342664-AP-332243

Records Request Print Provider Details
Date
7/17/2024
Report number
00342664-AP-332243
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0036(2)(b)(e) and (g)
Findings
The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about April 26, 2024, AV was identified as having had a significant change of condition related to multiple falls and from April 26, 2024, thorough July 7, 2024, AV had five additional falls with no changes made to AV's care plan. On June 21, 2024, AV's physician ordered a bed alarm as a fall intervention. The bed alarm was not put in place until July 1, 2024, and a temporary service plan to notify care staff of the intervention was not in place until July 11, 2024. On July 7, 2024, AV had another fall, resulting in a laceration and hospitalization for treatment. The facility failed to develop fall interventions to address AV’s fall risk, resulting in injury and hospitalization for treatment. The facility failed to plan care for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
ALFCP25-00204 $188.00 fine assessed