Violation Details: 00414302-AP-365546

Records Request Print Provider Details
Date
7/16/2025
Report number
00414302-AP-365546
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
411-054-0040(1)(a) and (d)
Findings
On or about July 16, 2025, the Alleged Victim (AV) was transported to the hospital due to unexplained bruising on the backs of the thighs and an elevated blood sugar reading. Hospital staff later reported that imaging revealed AV had a fractured pelvis. The attending physician estimated that the injury likely occurred within the previous three days. The facility’s internal investigation determined that multiple caregivers observed bruising between the night of July 14, 2025, and July 16, 2025; however, none of the staff reported or documented the bruising to facility nursing staff or management. Prior to being transported to the hospital on July 16, documentation indicated that AV’s pain level appeared to be “10/10,” as AV was reportedly screaming during assessment of the legs. Due to systemic failures in staff reporting and documentation of symptoms, the facility did not adequately monitor AV’s change in condition, resulting in a delay in the diagnosis and treatment of the pelvic fracture which is a violation of resident rights, is considered neglect of care which constitutes abuse, as defined by 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00212 $1125.00 fine assessed