- Date
- 4/23/2019
- Report number
- 00028368-AP-020039
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to assure timely medical treatment
- Result
- Substantiated
- Findings
- On or about April 23, 2019, Alleged Victim (AV) came out of his/her room with a head injury stating he/she had fallen. Staff described AV as not acting like his/her self as evident by not being able to answer questions appropriately, not using hand motions, and unresponsive to staff. AV went back to bed with staff monitoring his/her. On or about April 24, 2019, at approximately 5:00am AV, woke up and vomited. Progress notes describe AV as "drooling with lots of dark green mucus." At approximately 8:30am, AV began having trouble breathing, emergency services was called and AV was sent to the hospital where AV passed away. AV's POLST indicates "Limited Treatment and Comfort Care" if AV has a pulse and is breathing. The facility failed to provide appropriate medical treatment after AV's fall which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP20-00296 $15000.00 fine assessed