- Date
- 4/7/2024
- Report number
- 00323472-AP-275358
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) moved into the facility in approximately mid-November of 2023. Upon move in, AV had a blister on the top of the left foot and a blister on the top of the right hand. While living at the facility AV developed skin breakdown on the h/h bottom, genitalia, a cut to the left leg, redness to the left groin, and an open wound to the right chest. On April 7, 2024, AV was sent to the hospital with concerns for altered mental status and found to have an infection. AV was admitted in the hospital. AV hospital records indicate, numerous extremity and perineal wounds, and extensive wounds on AV buttocks, genitalia, chest and legs consistent with moisture and pressure injuries. Redness to AV’s groin was first documented on January 9, 2024. The cut on AV’s left leg was first documented on January 27, 2024. The skin breakdown/open areas on AV bottom and genitalia were first documented on February 13, 2024. The wound to AV’s chest was not documented by the facility and was not known by the staff. Despite AV’s worsening wounds and skin conditions, AV’s service plan dated February 17, 2024, only mentions, a yeast infection to h/h groin. Though AV’s service plan is dated 5 days after the skin breakdown/open areas were documented on AV’s bottom and genitals, there is no mention of these concerns in the care plan and there are no interventions or instructions for care staff to follow regarding AV’s wounds. The facility failed to properly plan care and implement appropriate interventions to address AV’s skin breakdown, resulting in the development of multiple pressure and moisture related wounds.
- Sanction
- RCFCP24-01033 $1500.00 fine assessed