- Date
- 6/22/2020
- Report number
- 00094202-AP-071168
- 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) had experienced a loss of appetite, has trouble chewing his/her food due to an issue with his/her dentures. AV was unable to cut up his/her own food due to weakness. AV's medication provider ordered interventions for AV's weight loss including but not limited too ensure daily, weekly weights and assistance with cutting up his/her food. Initially the ensure was put into AV's room so he/she could self administer the supplement, AV is not approved for self administration. The weekly weights were not entered into the medication administration record correctly, had multiple orders for weights that were not clear, AV's medical provider was not notified on AV's weights on multiple occasions. AV's dietary order to cut up his/her food was not processed according to the facilities policy so it is unclear if AV's food was getting cup up consistently and the medication administration record was not updated with the order to cut AV's food until approximately July 29, 2020. The facility failed to respond to AV's change of condition causing AV unintended weight loss of approximately twenty (20) pounds, increased weakness/dizziness and possibly contributing to increased falls. The facility's failure is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP20-00747 $3000.00 fine assessed