Violation Details: 00050009-AP-034799

Date
9/20/2019
Report number
00050009-AP-034799
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to administer medication as ordered
Result
Substantiated
Findings
The facility was responsible for administering Alleged Victim’s (AV) medications. AV had a medical order to increase his/her anticoagulant medication. On or about September 14, 2019, Alleged Perpetrator (AP2) erroneously confused AV’s medication order in the Medication Administration Record with another resident’s order and as a result, AV’s anticoagulation medication was suspended for approximately three days, placing AV at risk for harm. AP2’s action is considered neglect of care and constitutes abuse. The facility failed to provide sufficient oversight and monitoring of the medication system which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP20-00302 $1500.00 fine assessed