Violation Details: 00144366-AP-113965

Records Request Print
Date
5/10/2021
Report number
00144366-AP-113965
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide oversight and monitoring of change of condition
Result
Substantiated
Rule(s) Violated
External site: 411-054-0027 (1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0040(1)(b) and (c)
External site: 411-054-0070(1)
Findings
Alleged Victim (AV) relies on the facility for his/her care. On or about May 10, 2021 AV developed a Stage I pressure wound. By June 08, 2021 pressure wound progressed to Stage II. AV’s wound care needs increased to every day or every other day. Hospice provided scheduled wound care but was not present to meet all wound care needs. The facility did not have adequate staffing to meet the needs of AV. The severity of AVs wounds could have been prevented by providing more wound care and by turning/reposition AV more often. The facility failed to provide oversight and monitoring of change of condition and provide adequate staffing, which is a violation of residents rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP22-00204 $500.00 fine assessed