- Date
- 3/10/2025
- Report number
- 00388325-AP-338820
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- On or about March 10, 2025, AV suffered a fall which resulted in a head injury resulting in AV being sent to hospital for treatment. Based on facility documentation and interviews, at time of fall, AV was in his/her room self-transferring from his/her wheelchair to the recliner after using restroom. While self-transferring, AV fell hitting AV's head on a table, then AV pressed the pendent button and was found on the floor by facility staff. AV's observation notes between January 5, 2025, and March 10, 2025, AV suffered five falls. At time of incident, AV's care plan was not being followed; AV did not receive a safety check at 1pm. Facility records indicate AV fell at 1:40pm while attempting to self-transfer after toileting without assistance. The March 10, 2025, fall resulted in injury and hospitalization, and this was fall was determined preventable if AV had been checked on at 1pm and offered assistance with toileting as care planned. The facility's failure resulted in AV experiencing an unwitnessed fall, was transferred to the hospital and required staples in his/her head, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP25-00321 $375.00 fine assessed