- Date
- 8/14/2024
- Report number
- 00348772-AP-299264
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- According to the documentation, the facility failed to care plan appropriate fall interventions for the Alleged Victim’s (AV) known fall history. On or about June 21, 2024, and June 30, 2024, the AV experienced two falls sustaining head injuries. On or about July 21, 2024, facility documentation instructed staff to implement 2-person transfers for the AV and for toileting assistance. On or about July 22, 2024, AV suffered a witnessed fall in the hallway after they became dizzy and fell. A service plan update for the AV’s service plan instructed staff verbally to implement 2-hour safety checks and provide verbal reminders to the AV to use their call button for assistance. On or about August 14, 2024, the AV was found on the floor of their apartment and reported significant pain. The AV was sent to the ER and was found to have a vertebral fracture due to the fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP24-00842 $375.00 fine assessed