- Date
- 6/25/2024
- Report number
- 00350336-AP-300715
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a long history of choking. AV Service Plan dated on or about March 30 2024, indicates regular diet and AV able to make own choices on what to eat and drink. On or about June 25, 2024 AV had a choking episode, which resulted in AV receiving a choking procedure from staff. According to staff interviews, AV was on a mechanical soft diet at the time of incident on June 25, 2024, and there was confusion regarding AV's diet texture, and was posted differently from Service Plan and meal log posted in kitchen. AV had another choking episode on July 4, 2024, where AV choked during lunch but was able to clear the food independently. The facility failed to update AV's Service Plan in a timely manner, leading to staff confusion regarding AV's diet, conflicting diet plans and resulting in AV choking and requiring a choking [procedure] to be performed on June 25, 2024, and another choking episode on July 4, 2024, putting AV at risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-01197 $500.00 fine assessed