- Date
- 3/30/2022
- Report number
- 00194716-AP-155880
- 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
- Findings
- The Alleged Victim (AV) had suffered a stroke in the past; On or about March 30, 2022, Witness #2 (W2) was on the phone with AV, when s/he began to exhibit symptoms of slurred speech and incoherence. W2 contacted the facility while remaining on the phone with AV, and requested facility staff check on AV, for signs of a stroke. Alleged Perpetrator #2 (AP2) was at the facility, however, failed to assess or appropriately respond to AV's significant change of condition according to 411-054-0045(1)(f), but requested another staff person check on AV. Staff checked and determined through observation from AV’s door, that AV’s speech was slurred due to holding the phone to his/her face. During night shift, on or about March 30, 2022, Alleged Perpetrator #3 (AP3) noticed AV was acting abnormally and outside of his/her baseline, however, did not consult AV’s service plan, nor request an RN assessment. Upon observing AV the morning of March 31, 2022, day shift staff called emergency services to take AV to the hospital. AV was admitted to the hospital, diagnosed with having suffered a stroke and a Urinary Tract Infection, was septic and hypoxic. The facility failed to appropriately care plan related to AV’s past medical history, describe signs or symptoms for staff to look for, and instructions for a change of condition. The facility's, AP2's and AP3's failures are a violation of resident rights, are considered neglect of care and constitute abuse.
- Sanction
- ALFCP23-00133 $500.00 fine assessed