- Date
- 1/19/2021
- Report number
- 00121481-AP-094262
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- On or about January 19, 2021, Alleged Victim (AV) was admitted to the hospital in the ICU due to failure to thrive, dehydration, and hypernatremia. Based on facility documentation and interviews, AV was not swallowing his/her food a week prior to hospitalization. AV's care plan stated that staff were to report changes in AV's ability to eat or drink to the facility nurse. There was no documentation of AV having changes in his/her eating or drinking ability. There was no documentation of staff contacting or working with AV's doctor regarding these issues. AV's service plan also stated that staff were to weigh AV once a month. Facility records showed that AV was weighed on November 1, 2020, and was not weighed again until January 20, 2021, which is 80 days later. AV had lost 21 pounds during that 80 day timeframe which was a 10.8% decrease in AV's weight. At the hospital, AV's assessment outline AV had multiple issues related to dehydration. The facility's failure to provide adequate assistance with nutrition and hydration, caused AV unreasonable discomfort, undesired weight loss, and serious harm which is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- RCFCP24-00843 $1500.00 fine assessed