Violation Details: 00051616-AP-035901

Date
9/29/2019
Report number
00051616-AP-035901
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to administer medication as ordered
Result
Substantiated
Findings
The facility was responsible for managing all of Alleged Victim’s (AV) medications. From approximately September 26, 2019 through September 29, 2019, the facility failed to administer AV’s anticoagulant medication due to the order not being approved in the Medication Administration System (MAR), putting AV at risk of harm. Facility documentation indicates that multiple staff were involved in the MAR error. From approximately September 19, 2019 through September 25, 2019, the facility failed to ensure AV’s hypertension medication was available to administer. 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
ALFCP20-00300 $375.00 fine assessed