- Date
- 1/6/2025
- Report number
- 00375643-AP-326035
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- According to the documentation, the facility failed to care plan for increased ADL needs for the Alleged Victim (AV) after they sustained an injury fall which increased their care needs. On or about December 29, 2024, the AV sustained an injury fall down the stairwell. After this fall, the AV required more assistance with ADLs and assistance with transferring to use the bathroom. Staff were to check on the AV 8 times a shift to ensure the resident did not try to self-transfer and to assist with the restroom. A service plan update indicated the AV was at a higher risk of skin breakdown due to their change of condition and staff were to notify the appropriate staff if there were signs of skin breakdown. On or about January 06, 2025, the AV was found to be sitting in a pool of loose liquid stool and a stage 2 pressure sore was found in the AV’s groin area. The facility failed to implement appropriate interventions to ensure skin breakdown did not occur, leading to a new pressure sore, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP25-00162 $750.00 fine assessed