Violation Details: 00081632-AP-060639

Records Request Print
Date
4/29/2020
Report number
00081632-AP-060639
Type
Abuse: Neglect
Level
4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation
Failed to assure food safety
Result
Substantiated
Rule(s) Violated
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0030(1)(a)(A)
Findings
Alleged Victim (AV) has an order for thickened liquids. On or about April 29, 2020, Alleged Perpetrator 2 (AP2) gave AV a drink of thin liquids during medication administration in the dining room causing AV to aspirate. AV was transported to the emergency room, diagnosed with aspiration pneumonia and later passed away. The facility did not have any documented procedures in place to ensure residents requiring thickened liquids were served appropriate drinks in the dining room. The facility failed to assure food safety, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
RCFCP20-00911 $2500.00 fine assessed