- Date
- 9/30/2024
- Report number
- 00360937-AP-311287
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- According to the documentation, the facility failed to appropriately care plan interventions for the Alleged Victim’s (AV) change of condition. On or about August 29, 2024, the AV experienced a change of condition which triggered them to spend more time in the seated position. The facility did not update the service plan for interventions to do skin checks on the AV after the change of condition. On or about September 30, 2024, the facility was notified by a family member of a red spot on the AV’s buttocks. The facility found a red spot on the buttocks and notified the facility RN of the skin issue. On or about October 1, 2024, the facility nurse looked at the spot and found a dime sized red spot with skin peeling around the skin wound. The AV was then admitted to the hospital on or about October 2, 2024. An RN from the hospital called the facility on this date and notified them of the three pressure wounds, two of which needed to be drained. The facility’s failure to implement appropriate interventions after the AV experienced a change of condition resulted in multiple pressure wounds, two of which needed to be drained, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP25-00099 $1125.00 fine assessed