Violation Details: 00360336-AP-310652

Records Request Print
Date
10/7/2024
Report number
00360336-AP-310652
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide service
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility for care. The facility manages AV's oxygen supply to include ordering as well as setting up AV with portable oxygen devices so AV can be in the common areas of the facility. According to an investigation, multiple times the facility staff were not completely turning off the portable canisters after use and staff were often increasing AV's oxygen flow to 4 L/min, despite a physician order for only 2 L/min. This resulted in AV running out of oxygen in the portable canisters, causing AV distress and requiring AV to be confined in their room until new canisters were delivered. The facility failed to provide appropriate services, regarding care planning and oxygen orders, which caused unreasonable discomfort and AV distress, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP25-00243 $500.00 fine assessed