- Date
- 11/5/2025
- Report number
- 00437248-AP-389230
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for their care. AV is bedbound and requires repositioning every two hours and AV has an air mattress to prevent pressure sores. AV's outside provider ordered wedges to help keep AV in position to offload pressure on AV's pressure wounds. According to an investigation, AV's mattress has been found on multiple occasions to not be inflated, resulting in AV having direct pressure on the wounds. The wedges ordered by outside provider were received in the mail but misplaced in the facility and not implemented. Staff are repositioning AV up to every four hours, instead of every two hours. The facility failed to follow the care plan and/or implement interventions, resulting in AV’s pressure wounds worsening over time, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP26-00346 $1500.00 fine assessed