- Date
- 12/19/2024
- Report number
- 00373238-AP-323620
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for care and assistance with their medications, has been on oxygen at night for approximately 6 years, and has a history of confusion when ill or oxygen is low. There is no mention of AV requiring oxygen in AV's care plan, and a no oxygen orders on the Medication Administration Record (MAR) until January 2025. AV was placed on alert charting on approximately December 17, 2024, due shortness of breath (SOB) and weakness with little to no specific interventions. During the time AV was on alert charting for SOB and weakness, AV's oxygen saturations were only taken 6 times out of 77 charting notes. On or about December 19, 2024, AV went to the hospital due to AV's oxygen levels being in the 70's and returned home with an as needed nebulizer treatment. According to an investigation, AV was not receiving their nebulizer treatment after return from the hospital due to the need for AV to request it, which AV was not doing due to their confusion. On December 31, 2024, AV's POA took AV to see their physician and the nebulizer treatment was changed to scheduled rather than as needed. AV started improving shortly after. The facility failed to provide services, to include implementing effective interventions and/or properly care planning and ensuring a safe medication system, which is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP26-00034 $1000.00 fine assessed