- Date
- 5/16/2024
- Report number
- 00331421-AP-285925
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- The facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs and wound care. On May 16, 2024, AV had a skin irritation/tear on his/her buttocks area. Home Health gave instruction to facility on how to care for wound due to Home Health ending. At time of Home Health ending care services for AV, the area of irritation was about the size of a quarter with no open wound. Based on interviews and facility documentation, by June 2, 2024, AV was sent to hospital for lump at rectal area and was admitted for infected ulcer. An investigation determined the facility failed to follow directives on wound care resulting in AV sustaining a stage 4 pressure wound. The facility's failure resulted in AV’s condition worsening causing further unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00035 $2500.00 fine assessed