Violation Details: 00059254-AP-042161

Date
11/21/2019
Report number
00059254-AP-042161
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Findings
The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) MAR was clear to staff. On or about November 21, 2019, Alleged Perpetrator #2 (AP2) administered medication to AV that was meant only for end of life, and then gave AV pain medication less than one hour later. AV was then found on the floor from a fall, with an injury to his/her head and chest. AP2’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP20-00342 $169.00 fine assessed