Violation Details: 00236214-AP-193674

Records Request Print Provider Details
Date
12/11/2022
Report number
00236214-AP-193674
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings
On or about December 11, 2022, the facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs which resulted in AV choking on a piece of meatball, approximately 1 inch in length and width. Based on facility documentation and interviews, AV's food needs to be pureed and/or mashed due to AV's choking risk. At time of incident, AV's meatball was not pureed and/or mashed causing AV to choke. After W4's, W5's, W3's, and W6's attempt at dislodging the meatball from AV's throat, W2 was finally able to get the piece of meatball out. The failure resulted in AV’s suffering unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00233 $1125.00 fine assessed