- Date
- 2/28/2025
- Report number
- 00386324-AP-336842
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. Night staff are to provide routine nightly checks, three (3) to four (4) times at night. On or about February 28, 2025, at 9:30 AM, Witness 3 (W3) went to AV's room and heard a muffled sound, looked for AV and saw AV was on the bathroom floor face down. When AV was found, AV’s room smelled strongly of bowel movement and AV had diarrhea from the waist down. W3 called all staff to address the situation; staff tried to assist AV up, but AV complained of pain and staff was unable to get AV up. Staff called 911 and AV was sent to the hospital. AV stated AV was in the kitchen and had a diarrhea accident the night before. AV tried to go to the bathroom; AV fell and was unconscious. AV did not know how long AV was on the floor but estimated several hours. Hospital records estimated that AV was left on the floor in a soiled state for approximately 15 hours. The facility failed to follow the care plan by failing to conduct nightly checks on AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP25-01000 $188.00 fine assessed