- Date
- 3/20/2020
- Report number
- 00077022-AP-056833
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to intervene when resident's condition changed
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is a resident of the facility and relies on the facility to meet his/her basic needs. AV has a stoma and a colostomy bag that Home Health provides care for including ordering supplies. On or about March 12, 2020, AV was admitted to the hospital with abdominal distention, blood in his/her colostomy bag, nausea, and an inability to tolerate food or fluids. On or about March 16, 2020 and March 19, 2020, AV was transported to the emergency department due to redness and bleeding from his/her ostomy site. On or about March 20, 2020, AV ran out of colostomy bags. AV received colostomy bags on or about March 26, 2020.AV did not have colostomy bags available March 20, 2020 through March 26, 2020, at which time AV held washcloths up against his/her stoma to catch feces, did not sleep in his/her bed multiple nights to avoid soiling his/her bed, avoided walking and participating in activities that he/she normally would. The facility was aware AV did not have colostomy bags available and attempted to communicate with Home Health Agency to address the problem. The Home Health Agency did not return the facility's calls. The facility did not have any documented interventions in place to address AV's needs to obtain colostomy bags, or to assist AV with managing his/her colostomy without any bags available. The facility did not put interventions in place to address AV's known change in condition when he/she ran out of colostomy bags, leading to AV managing his/her fecal waste from his/her colostomy with washcloths for multiple days, causing unreasonable discomfort and lack of personal dignity. The facility's failure is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP20-00637 $1500.00 fine assessed