- Date
- 2/26/2025
- Report number
- 00386109-AP-336608
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) moved into the facility on or about January 30, 2025. On or about February 26, 2025, AV was found at approximately 12:30pm laying on AV's back on the floor with Av's head against the AC unit, AV was last seen at approximately 9:30am. AV stated that AV was standing to go to lunch and fell backwards. AV was sent to the emergency room with a head injury and two skin tears to AV's right elbow. AV's service plan dated February 26, 2025, was indicated to be the plan in place at the time of AVs fall on February 26, 2025. The service plan indicates AV is independent with transfers and uses a walker to ambulate without assistance, AV needs stand by assistance with transfers on an as needed basis, AV may attempt to transfer alone before needing staff to assist, Staff to check in with AV and remind AV to use walker or other assistive device, AV is able to use the call light system without reminders, and is able to seek care assistance if needed. AV is a fall risk and has had falls prior to moving into facility. Prior to the fall on February 26, 2025, AV had falls with injury on or about February 10th, 23rd, as well as two falls occurring on the 25th, 2025. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP25-00462 $375.00 fine assessed