- Date
- 3/16/2023
- Report number
- 00253121-AP-208845
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to intervene when resident's condition changed
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) was noted to have a change of condition on February 4, 2023 and again on February 23, 2023. AV was noticed to be declining by many staff in the facility. AV's physician was not informed of the change of condition until March 13 2023 when the facility requested a hospice evaluation. AV was care planned for safety checks. On or about March 15, 2023, Alleged Perpetrator #2 (AP2) checked on AV at 8:00 PM, 10:00 PM, 11:00 PM and 11:50 PM. At 10:00 PM, AP2 stated that AV was on the floor, however, AP2 did not make contact with AV to see if AV needed assistance. At 11:00 PM, AP2 notes that AV was still on the floor, and still made no contact with AV for assistance. At the 11:50 PM check, AV was still on the floor and AP2 advises staff that AV is on the floor and has been for some time. Staff check on AV at approximately midnight and determine AV is not breathing. Staff called 911 and management, but did not attempt CPR, as AV is noted to have a DNR in place. When EMS arrived, it was discovered that AV did not have a valid DNR on file. AP2's failure to ensure resident safety is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to assess and intervene is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP23-00851 $1500.00 fine assessed