- Date
- 9/6/2025
- Report number
- 00425306-AP-376854
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for his/her care and has a history of refusing assistance with care. AV's care plan says AV may resist care, needs protection and supervision due to unsafe or inappropriate decisions, and directs staff to provide toileting assistance 2 times each shift. According to an investigation, on or about September 6, 2025, AV was found on the floor in the doorway near the bathroom during a safety check in the early morning hours. Care staff reported AV had been last checked two hours earlier, offered assistance with toileting but AV resisted care and toileting assistance. Following the fall, AV experienced pain and was sent to the hospital and diagnosed with a hip fracture. While AV's service plan said AV had resistive behaviors, there were no interventions for staff to implement to address the behaviors. The facility failed to properly plan care and address resident behaviors, which is a violation of resident’s rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP26-00170 $1500.00 fine assessed