Violation Details: 00058768-AP-041813

Date
9/17/2020
Report number
00058768-AP-041813
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Findings
Alleged Victim (AV) requires facility assistance with managing his/her medication. From approximately September 17, 2020 through September 29, 2020, AV was administered 5 mg of his/her blood thinning medication instead of the ordered 2mg. On or about September 30, 2020, AV's INR was checked and was abnormally high. AV was hospitalized from October 1, 2019 through October 8, 2019 for anemia due to acute blood loss related to his/her blood thinning medication. AV reported experiencing negative impact to his/her health due to the medication error. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
RCFCP21-01682 $500.00 fine assessed