Violation Details: 00374805-AP-325193

Records Request Print
Date
12/24/2024
Report number
00374805-AP-325193
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(a)(g) and (s)
External site: 411-054-0030(1)(e)(A)
External site: 411-054-0070(1)(b) and (2)(a), and (3)(a),(c), and (4)(b)(A) and (B) and (5)(a), (b)(A), and (B)
Findings
On or about December 24, 2024, Alleged Perpetrator 2 (AP2) and Witness 7 (W7) were transferring Alleged Victim (AV) from AV's bed to AV's wheelchair when AP2 stepped on AV's right foot. The toenail came off AV's right big toe as a result. AV service plan indicates AV requires a 2-3 person assist for all transfers or a Hoyer lift but AP1 doesn't have a Hoyer lift. AP2 was hired on or about November 27, 2024, and went through new hire orientation from approximately December 2, 2024, through December 3, 2024. AP2 was trained on elder abuse prevention, investigation and reporting on or about December 2, 2024, AP2 was not trained on gait belt safety and transfers until approximately January 27, 2025. The facility failed to a safe environment and provide supervision and training to AP2, resulting in an unsafe environment for AV.
Sanction
ALFCP25-00430 $500.00 fine assessed