Violation Details: 00206228-AP-166350

Date
7/7/2021
Report number
00206228-AP-166350
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) change of condition, to include swallowing difficulties, and physician orders. According to an investigation, in April 2020, AV's physician ordered an equivalent of a mechanical soft diet. On or about July 7, 2021, Home Health referenced the AV needing a mechanical soft diet with thin liquids. Neither of these were implemented by the facility. During a hospitalization on approximately June 26, 2022, it was documented that AV experienced a weight loss of approximately 24% and malnutrition, which placed AV at risk for harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00381 $250.00 fine assessed