Violation Details: 00124312-AP-096633

Records Request Print
Date
12/16/2020
Report number
00124312-AP-096633
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
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0040(1)(a) and (d)
External site: 411-054-0070(1)
Findings
The facility failed to assess, intervene, and monitor when the Alleged Victim (AV) experienced a change of condition. AV complained of pain, blood in urine and was transported to the hospital in early December for treatment and diagnosed with a urinary tract infection. AV was prescribed an antibiotic and appeared back to baseline. Mid December, AV had blood and pus in his/her brief, noticed by staff, however, it was not documented and AV was not placed on alert for this concern and no assessment was completed until late December, when AV was sent to the hospital for treatment again. AV passed away after one day in the hospital from sepsis due to urinary tract infection. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.
Sanction
RCFCP21-02228 $1500.00 fine assessed