- Date
- 6/3/2025
- Report number
- 00405658-AP-356668
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) had a progressive brain disorder that gradually destroys memory, thinking and other cognitive functions. In late 2024, AV developed a sore on AV's bottom while living in another facility. Facility was aware of this history, but staff were not aware. On or about June 3, 202025, it was discovered that AV had open areas to AV's buttocks. The facility did not put any interventions in place to prevent sores from developing. The facility should have put interventions in place to prevent wounds on AV's buttocks. AV was scheduled to be showered 2 times per week by 1-person as a total assist; the person was to wash AV's entire body, peri area and face/head as needed. Staff were supposed to complete shower sheets for everyone to document any skin issues. Witness 3 (W3) did not assess AV's skin in the shower; AP1 staff was supposed to do that. AV frequently refused showers. Staff were to call W3 when AV refused to shower after 3 times with change of face. W3 would come in to encourage AV when W3 was available per the Service Plan, but staff would go 3 to 4 weeks without contacting W3. The facility failed to follow the Service Plan around AV’s shower needs, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP25-01281 $375.00 fine assessed