- Date
- 10/22/2019
- Report number
- 00054698-AP-038521
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) was reportedly unwell and declining for approximately two weeks prior to the incident date. On or about October 22, 2019, AV was described as being awake, talking but unwell. AV had refused a visit to Elder Place, food, liquids, and medications. Elder Place was notified, and a nurse called back at approximately 9:30am and requested AV's vitals. Staff were unable to obtain vitals but described AV as awake and talking with staff, no indication of breathing issues or gargling noises and requested a nurse be sent out. Staff were instructed to monitor AV. Sometime between 11:30am and 12:00pm, the nurse arrived. The AV was in bed, tilted at a 45-degree angle. AV was reportedly starting to gurgle at this point with some saliva build up in his/her throat. The nurse collected urine and blood samples and administered a nebulizer treatment. Prior to the nurse departure, he/she spoke to one staff member outside of AV's door and instructed them to wait for a call from the physician and nebulizer orders. Around the same time of the nurses departure the AV had a bowel movement and while being assisted by staff, his/her bed was flattened. After staff were done assisting AV they did not move the bed back to a 45 degree angle. Staff reported making continual checks on AV throughout the afternoon, who reportedly continued to sleep flat on his/her back. Around 4:15pm, a staff member answered the facility phone and spoke to AV's physician, who reported he/she believed AV was dying and asked staff for his/her observations of AV. The staff member shared concerns about the AV's ability to breath, the fluid secretion and gurgling, and that he/she was afraid AV would choke to death. AV's physician instructed staff to call 911 immediately. Shortly after 4:20pm, paramedics arrived and observed AV lying flat on his/her back in bed, unconscious, with approximately 30 cc's of fluid in his/her mouth which was running down AV's face and neck, gargling phlegm up, and unable to breath. AV's records were not accessible to staff, as the staff did not have a key to the locked room. On or about October 24, 2019, while at the hospital AV passed away. AV's cause of death was pneumonia and fluid on the lungs due to aspiration. The facility failed to care plan appropriately according to AV's recent decline and failed to respond to AV's change of condition when the AV's condition became emergent which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP20-00992 $2500.00 fine assessed