- Date
- 9/28/2020
- Report number
- 00104397-AP-079614
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to assure resident was safe
- Result
- Substantiated
- Findings
- During the past few years, the facility failed to provide a safe environment and services for the Alleged Victim (AV). On or about September 2020, it was discovered that Alleged Perpetrator 2 (AP2) had not been giving medications on a regular basis to AV, placing AV at risk for serious harm. Alleged Perpetrator 3 (AP3) failed to ensure that AV was safe by not fully completing investigations for falls that AV had and determining the origin of injury or reporting these falls with injury to Adult Protective Services (APS) or updating AV's care plan to reflect interventions or his/her extensive care needs. Alleged Perpetrator 4 (AP4) failed to ensure that all prescribing orders were updated in AV's Medical Record, and because of this failure, AV went without crushed medications and wound care. AP4 also failed to report abuse or neglect to APS, placing AV at risk for serious harm. Alleged Perpetrator 5 (AP5) failed to ensure the safety of AV by not having oversight of missed medications, failure to adequately cover nursing responsibilities and failure to notify APS of staffing issues at the facility, placing AV at risk for serious harm. The facility failed to have oversight of all of these items, placing AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.