Date: 2/22/2018
Report Number: GB186280
Allegation: Failed to provide a safe medication administration system
Type: Neglect
Level: 2 - Minor harm or potential for moderate harm
Description: On or about February 13, 2018 the facility ran out of Resident #1's medication due to not ordering it in a timely manner. Resident #1 missed approximately nine doses. On or about February 19, 2018, the facility ran out of a different medication for Resident #1 due to the facility not ordering it in a timely manner. Resident #1 missed approximately twelve doses of that medication. Resident #1 experienced withdrawal symptoms such as but not limited to increase in blood pressure, sleepiness, red face, lethargy, night sweats, clammy skin, feeling cold, weakness, shakiness and generally not feeling well. The facility failed to provide a safe medication administration system which is a violation of resident rights, is neglect of care and constitutes abuse.
Rule(s) Violated: 411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Result: Substantiated
Findings: The facility failed to provide an adequate medication system.
Sanction: ALFCP18-254 $1500.00 fine assessed