Violation Details: 00355737-AP-306470

Date
8/21/2024
Report number
00355737-AP-306470
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide oversight and monitoring of change of condition
Result
Substantiated
Findings
The Alleged Victim (AV) relies on the facility to assist with activities of daily living. According to an investigation, on or about August 11, 2024, the AV was placed on alert charting related to a pressure ulcer on the right foot. Wound care instructions left by a medical provider were not implemented. A change in the condition of the AV's lower right extremity, including swelling, redness, and being hot to the touch, were not monitored or documented. The AV was admitted to the hospital and presented with sepsis secondary to right lower extremity cellulitis. The facility failed to implement wound care as ordered and to monitor the AV's changes in condition, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.
Sanction
ALFCP25-01029 $500.00 fine assessed