Violation Details: 00234296-AP-191861

Records Request Print
Date
11/11/2022
Report number
00234296-AP-191861
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide safe environment
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: 411-054-0036(2)(g)
External site: 411-054-0070(2)
Findings
The Alleged Victim (AV) was care planned to have oxygen at all time. On or about November 11, 2022, AV was taken to the dining area with his/her portable oxygen tank. The tank was checked for fullness and deemed to be full by staff. After AV's meal, he/she was taken back to his/her room and stood up out of his/her wheelchair and became unresponsive. Emergency services were called and AV's oxygen saturation was at 41%. AV was taken to the hospital and returned later that day once his/her oxygen level had returned to baseline. The facility's failure to ensure proper training regarding AV's oxygen parameters, the length of time that a portable oxygen tank will last or how to properly ensure the portable tank is put together properly to ensure that it is working correctly. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00238 $500.00 fine assessed