- Date
- 4/22/2025
- Report number
- 00396832-AP-347496
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to maintain a safe physical environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility to provide a safe physical environment and for assistance with cares. According to an investigation, on or about April 20, 2025, the facility call system was not operating. There were not specific instructions for re-setting the call system and staff on shift were not able restore the operation of the call system. The AV called for assistance, the call was not received and the AV attempted to transfer independently and fell. The AV was not found on the floor by staff until approximately an hour later. The AV experienced unreasonable discomfort, skin tears, and bruising. The facility failed to ensure the call system was operational and that staff were instructed on how to address system outages, which is a violation of resident’s rights, is neglect of care, and constitutes abuse
- Sanction
- ALFCP25-00355 $188.00 fine assessed