Violation Details: 00366390-AP-316649

Records Request Print Provider Details
Date
7/12/2024
Report number
00366390-AP-316649
Type
Abuse: Neglect
Level
4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation
Failed to provide oversight and monitoring of change of condition
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)(g)
411-054-0040(1)(b), (c)
Findings
The facility failed to appropriately care plan related to the Alleged Victim's (AV) fall history. AV suffered two falls in June 2024, one of which resulted in a fractured sacrum. AV began showing signs of dehydration, weakness, and difficulty with ambulation at the end of June 2024 and the beginning of July 2024. On July 8, 2024, AV was evaluated for a change of condition due to significant weight loss. AV had suffered three more falls in July 2024 before passing away on July 16, 2024. AV fell a total of five times between June 6, 2024, and July 13, 2024. Based on facility documentation and interviews, the facility failed to provide oversight and monitoring of AV's change of condition by failing to ensure AV's service plan was reflective of AV's care needs due to AV's health decline and increased fall risk. The facility's failure caused AV to suffer avoidable pain and unreasonable discomfort over time, which is a serious violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP25-00390 $1500.00 fine assessed