- Date
- 3/13/2025
- Report number
- 00389081-AP-339592
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- On or about March 13, 2025, Alleged Victim (AV) was observed by facility staff actively trying to self-transfer in which facility failed to intervene and assist AV which resulted in AV suffering a fall with injury. AV is care planned as a full assist in ambulation and transfers and AV should not be left alone when observed actively trying to transfer independently. Based on facility documentation and interviews, AV had a change of condition on or about January 15, 2025, due to weakness resulting in AV needing full assist with transfers. Facility records show that AV had 6 unwitnessed falls since AV's change of condition, with all falls happening while AV was self-transferring. The facility failed to adequately monitor and failed to provide appropriate oversight of AV's care needs which resulted in AV experiencing multiple injury falls and repeated unreasonable discomfort, which is a moderate violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly failed to follow AV's care plan. An investigation determined that no abuse occurred by AP2, due to facility failing to provide clear direction regarding the delivery of AV's services.
- Sanction
- ALFCP25-00410 $1013.00 fine assessed