- Date
- 10/6/2025
- Report number
- 00433171-AP-385065
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) resides in the Respondent’s facility and depends on staff to meet basic needs and ensure safety. AV has a documented history of falls, including incidents in August and September 2025. AV’s service plan dated on or about August 26, 2025, notes poor gait, weakness, decreased mobility, and use of both a walker and wheelchair. AV utilizes an upright walker within AV’s apartment, requires one-person staff assistance for wheelchair mobility over longer distances, and requires two-person assistance for transfers.
On or about August 29, 2025, AV was unable to stand from the wheelchair despite three attempts. On or about September 4, 2025, AV was recertified for physical therapy, AV was assessed as requiring extensive assistance for all transfers and bed mobility and was noted to be non-ambulatory.
On or about October 6, 2025, AV self-transferred from the wheelchair to the sink and fell in AV’s bathroom. Following this fall, interventions directed AV to call for assistance and wait for staff before attempting transfers. On or about October 10, 2025, AV sustained an unwitnessed fall in AV’s room. AV reported leaning too far, falling out of bed, and landing on AV’s side next to the bed. AV was not wearing a call pendant and yelled for help. AV sustained injuries to the face, left knee, left arm/elbow, and back of the head. Interventions following this fall included having the family obtain a grabber tool and instructing AV to call staff for assistance.
The Respondent failed to develop and implement person-centered interventions sufficient to mitigate the known fall risk to AV. This failure constitutes abuse by neglect.
- Sanction
- ALFCP26-00109 $500.00 fine assessed