- Date
- 4/28/2025
- Report number
- 00398151-AP-348834
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- During a shift change on or about April 28, 2025, Alleged Victim (AV) requested assistance with his/her Activities of Daily Living (ADLs). Alleged Perpetrator 2 (AP2), an employee of the facility, responded to AV's request for assistance. Shortly after AP2 began to assist AV with toileting, AP2 stated to AV that he/she needed to check on another resident. AP2 had partially taken AV's clothes off when he/she left AV unattended during toileting. Based on facility documentation and interviews, no other resident had pressed their call pendant during the time that AP2 was with AV. AV is a fall risk and requires assistance with all care relating to toileting, bathing, and dressing. The investigation concluded that AP2 abandoned AV by leaving AV in the restroom while in the middle of providing care to AV, resulting in AV being left alone for approximately 10 to 15 minutes, placing AV in a situation in which AV was exposed to a potential for serious risk of harm due to AV's known fall risk. AP2's actions is considered abandonment of care which is considered abuse. The facility is responsible for the supervision, training, and overall conduct of AP2 when AP2 is acting within the scope of his or her employment duties. Based on facility documentation and interviews, AP2 received a performance improvement notification on February 20, 2025, due to AP2 not providing care to another resident of the facility when this resident requested assistance. AP2 did not receive any additional training or guidance after receiving his/her first Non-Compliance Notice nor did AP2 receive training after the 2 Performance Improvement Notifications. The facility failed to provide adequate oversight and training to AP2, resulting in AP2 abandoning AV in the restroom when he/she was in the middle of providing care to AV which caused AV emotional harm, unreasonable discomfort, and placed AV at risk for a serious fall with injury. The facility's failure is a moderate violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- ALFCP25-00386 $375.00 fine assessed