- Date
- 6/13/2025
- Report number
- 00408389-AP-360123
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- On or about June 13, 2025, Alleged Perpetrator 2 (AP2) failed to follow the Alleged Victim’s (AV) care plan by attempting a one-person transfer, despite AV being designated as a two-person assist. According to facility documentation and staff interviews, AP2 initially called for assistance when AV needed to be transferred. However, when no one responded to AP2's call for assistance, AP2 proceeded to transfer AV alone from the recliner to the wheelchair. AP2 knowingly performed the transfer with the knowledge that AV was a two-person assist. During the transfer, the wheelchair, which was unlocked at the time of incident, moved causing AV to fall and sustain scrapes to his/her lower back and left hip. When assistance arrived, AV was found on the floor with AP2. AV sustained physical injury resulting in unreasonable discomfort. AP2’s actions are considered neglect of care, which constitutes abuse. The facility failed to ensure that AP2 was adequately trained to provide appropriate care for AV, particularly in situations where staff were not available to assist upon request. The facility is responsible for the supervision, training, and overall conduct of AP2 while acting within the scope of their employment duties. This failure to provide proper training and oversight caused AV unreasonable discomfort a result of AP2 not following AV's care plan which is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- ALFCP25-00460 $250.00 fine assessed