- Date
- 1/20/2025
- Report number
- 00378797-AP-329254
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The facility failed to assess and implement appropriate interventions after the Alleged Victim (AV) experienced two balance-related incidents within three days. On or about January 17, 2025, AV lost balance during an activity, brushed against a fireplace, and reported pain. Despite AV’s known fall history, no new interventions were implemented. On or about January 20, 2025, AV fell again while putting on nonskid socks, resulting in fractured ribs. By failing to respond appropriately to the first incident, the facility allowed a preventable risk to escalate, culminating in the second fall and injury. Based on facility documentation and interviews, the facility failed to appropriately care plan by not implementing reasonable interventions to address AV's fall risk, which is a violation of resident rights, constitutes neglect of care, and is considered abuse.
- Sanction
- ALFCP25-00447 $375.00 fine assessed