- Date
- 3/6/2025
- Report number
- 00388125-AP-338833
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) was admitted into the AP1 on or about March 4, 2025. AV's service plan dated on or about March 4, 2025, indicates, medication management, AP1 administers medications, AV is no longer able to manage AV's medication routine, staff are to store, order, and safely administer all of AV's medications per AV's PCP's orders. Integumentary, skin treatments, AV is independent with all skin care and currently has redness to AV's pannus. Pain and non-drug interventions, indicates that PRN medication relieves pain, but there was no PRN medication on the MAR for AV. AV is able to express pain location and how severe it is and staff to notify MT/LN of any concerns of pain. AV's MAR indicates topical medicine to treat rash to be applied topically four times daily to rash in pannus area and to notify nurse of side effects, skin irritation, burning, itching, rash, eczema, and pain. Starting on or about March 6, 2025, AV declined the topical medicine to treat rash due to AV associating pain to AV's rash with the medication administration. On or about March 7, 2025, AV's rash increased in redness, had slightly open areas, drainage, moisture, signs of infection, pain and foul odor. AV was in pain due to AV's brief sticking to AV's skin and while pulling up the folds of AV's pannus, AV requested PRN pain medications which there were none available to AV. AV continued to refuse prescribed topical medicine for rash, and continued to complain of pain, and making suicidal statements related to the pain from the rash. On or about March 10, 2025, AV's rash was noted to be extremely red, smelled foul and be extremely painful, AV requested a PRN pain medication which was not available to AV. AV was transported to the ER on March 10, 2025, with significant pain and suicidal ideation. AP1 failed to follow up on PRN medication for AV's increased and ongoing pain, and AV's medication refusals, which resulted in AV having suicidal ideation from pain and being admitted to the hospital for increased infection, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01054 $500.00 fine assessed