- Date
- 1/17/2022
- Report number
- 00179808-AP-143091
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The facility failed to provide appropriate services for Alleged Victim (AV) according to his/her care needs for assistance with incontinence care, skin checks, and behaviors for refusal of care. On or about January 17, 2022, AV was sent to the hospital for significant change of condition. Based on facility documentation and interviews, while AV was hospitalized, hospital staff observed six different tissue pressure injuries to AV's body. The pressure injuries were located on AV's left and right buttocks, right hip, right lateral foot, right medial foot, and left lateral foot. Some of these wounds were quite deep and were noted by hospital staff to be most likely caused by prolonged pressure and limited movement. The facility's failure to properly care plan for AV's behavior to refuse care, caused AV to not receive proper and timely incontinence care and skin checks, which resulted in AV developing pressure sores and experiencing pain and unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP23-00533 $1500.00 fine assessed