- Date
- 3/21/2024
- Report number
- 00319956-AP-271807
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to administer ordered medication
- Result
- Substantiated
- Findings
- Alleged Victim 's (AV's) service plan states that AV is independent in toileting cares. AV is to receive brief checks, changes and peri care daily for incontinence. AV has been found in urine-soaked briefs, clothing and/or bedding on several different occasions. AV is to receive showers every Wednesday and Saturday PM and PRN. AV has missed showers with no evidence of AV receiving a shower at an alternate day and/or time. AV's skin concerns are to be logged on shower sheets for RSM/LPN and to make a Med Tech aware. Starting on or about February of 2024, AV was found to have a rash on AV's lower back tailbone area that progressively worsened throughout February and March and spread onto AV's thighs. AV's rash on AV's tailbone and thighs was first noticed on or about February 7, 2024 and logged on the shower sheet. AP2 did not know about AV's rash until approximately February 23, 2024. AP2 checks the shower logs every Monday. AV has had a prolonged rash that has caused pain to AV for over a two-month period. AV's MAR and doctors' orders are to be followed as written by the Primary Care Physician. On or about March 21, 2024, AP2 applied another resident's barrier cream with menthol in it on AV's rash; the barrier cream is not on AV's MAR and is not a part of AV's doctors' orders. AP2 did not follow AV's doctors' orders and MAR. AP2 directed other care staff to apply a barrier cream belonging to another resident to AV's rash. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to provide services, and safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-01029 $500.00 fine assessed