- Date
- 6/7/2025
- Report number
- 00406378-AP-357517
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) has a known history and pattern of unsafe smoking in his/her room, using an open flame while he/she is on a continuous oxygen nasal cannula. On or about June 7, 2025, staff responded to AV's room after they heard AV screaming for help. When staff opened AV's door, and the room was filled with smoke and observed visible flames. Staff called for assistance and removed AV from the room and evacuated all residents from the facility. AV's nasal cannula was melted to AV's face and AV's face was black from smoke. AV was taken to the hospital and diagnosed with second degree burns to his/her head and face. During the time leading up to this incident, staff had noticed smoke in AV's room, from AV engaging in smoking marijuana from a pipe and pre rolled joints with an open flame. AV's care plan does not contain preventative measures to address AV's known behaviors of unsafe smoking in AV's room. The facility's failure to address AV's risk of serious harm by using an open flame while using supplemental oxygen is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00669 $375.00 fine assessed