- Date
- 11/26/2019
- Report number
- 00066718-AP-048269
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide peri care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) entered into Hospice care on or about November 26, 2019, due to steady decline and received an indwelling urinary catheter. Staff were not provided any information on how to appropriately care for a catheter, including how to monitor output, how to provide necessary catheter care to AV's genitals, and where to position the catheter tubing and bad. On more than one occasion AV's catheter was partially pulled out either due to AV inadvertently pulling on the catheter while toileting, or AV running over the catheter tubing with his/her power wheelchair. On or about January 1, 2020, AV received his/her quarterly evaluation in which AV was noted to require assistance with safety checks, bathing, catheter care, supplemental oxygen, and assistive device. AV's service plan dated January 8, 2020 states that AV ambulates using a walker and does not mention that AV is on hospice or has catheter care. Facility staff did not have access to AV's quarterly evaluation. On or about January 22, 2020, AV's care plan was updated to include catheter care. The facility failed to care plan around AV's catheter care and failed to ensure that AV's service plan accurately reflects AV's abilities or significant care needs, which resulted in risk of significant harm to AV. The facility's failure is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP20-00608 $500.00 fine assessed