- Date
- 3/18/2025
- Report number
- 00390017-AP-349381
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- • The Alleged Victim (AV) relies on the facility for care, requires assistance with eating and drinking, and is a high risk for aspiration. On or about March 18, 2025, AV was being fed by Witness 4 (W4), while W4 was visiting AV in the facility. At the conclusion of the meal AV vomited and had low oxygen levels and AV was taken to the hospital where it was determined AV had an aspiration event. According to an investigation, AV was previously care planned for staff to intervene if W4 was not following AV's feeding precautions, to prevent AV from aspirating, but that part of the care plan had been removed from the care plan. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s known risk of aspirating during feeding by W4, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01388 $375.00 fine assessed