Violation Details: 00360310-AP-310624

Records Request Print
Date
10/13/2024
Report number
00360310-AP-310624
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), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0036(2)(g), 411-054-0040(1)(d)
Findings
The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of recent falls. According to an investigation, on or about October 13, 2024, AV fell while attempting to open a courtyard door which was a long distance from AV's normal walking route. AV's service planned interventions were for staff to encourage AV to use a call light for assistance with walking. AV is resistive to using a call light. The facility did not develop or implement any known changes to AV's care plan to reduce the risk of falls. The facility failed to develop and implement fall interventions to address AV’s fall risk, resulting in a head injury and hospitalization. The facility failed to properly care plan for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction
ALFCP25-00147 $1125.00 fine assessed