- Date
- 7/16/2025
- Report number
- 00414302-AP-427100
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- On or about July 16, 2025, the facility failed to provide appropriate services as required by the Alleged Victim’s (AV) care plan and assessed needs. As a result of this failure, AV was admitted to the hospital after reporting significant pain of unknown origin and was subsequently diagnosed with a pelvic fracture. Facility documentation and staff interviews indicate that management was not aware of any incident that may have caused the injury. At the time of incident, staff were required to use a gait belt for all transfers; however, it had become common practice for staff to assist AV without a gait belt. Management was not aware that staff were inconsistently using the required transfer equipment. The facility's failure to provide adequate oversight of staff to ensure AV's care plan was followed, resulted in physical harm when AV sustained a pelvic fracture during a transfer 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). Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.
- Sanction
- ALFCP26-00212 $1125.00 fine assessed