- Date
- 9/13/2019
- Report number
- 00065045-AP-046893
- 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) required medication management and administration by the facility. AV had a medical order to suspend his/her anticoagulant medication from September 13, 2019 to September 16, 2019 for an upcoming scheduled surgical procedure. Alleged Perpetrator (AP2) erroneously switched AV’s order in the Medication Administration Record with another resident’s medication order and did not suspend AV’s medical order. On or about September 14, 2019, AV was administered his/her anticoagulant medication, resulting in AV’s surgical procedure to be postponed and causing AV to continue in pain. 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
- ALFCP20-00301 $1125.00 fine assessed