Violation Details: 00301279-AP-254470

Records Request Print Provider Details
Date
12/11/2023
Report number
00301279-AP-254470
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to meet the scheduled and unscheduled needs of residents
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(A) and (G)
411-054-0036(2)(g)
411-054-0037(1)(c),(e), and (g)
Findings
During the overnight shift of December 11, 2023, Alleged Victim (AV) pushed AV's call button several times, to request support with his/her Activities of Daily Living for night care as care planned. AV needed transfer assistance with incontinence care and to smoke a cigarette, PRN medication to manage his/her pain, and a drink of water for relief to quench thirst. As a result of facility's staffing levels not being sufficient at the time of incident, AV soiled his/her bed and was left in his/her soiled bed "all night". Based on facility documentation and interviews, the facility was unable to provide evidence as requested for investigation to show staffing levels at time of incident were sufficient to meet the scheduled and unscheduled needs of residents. The facility is licensed for 61 beds. During the overnight shift of December 11, 2023, when this incident occurred, there were only three staff taking care of the entire facility needs. At time of incident, AV was care planned as a two-person assist in a Hoyer lift. The facility's failure to provide adequate staffing support, resulted serious emotional harm due to staff not being able to adequately address AV's nighttime support needs and requests. Alleged Perpetrator 2 (AP2) allegedly neglected AV at time of incident. An investigation inconclusively determined no licensing violation or abuse occurred by AP2.
Sanction
RCFCP25-00737 $500.00 fine assessed