Violation Details: 00087876-AP-065899

Date
6/9/2020
Report number
00087876-AP-065899
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) relies on the facility to manage his/her medication. On or about June 9, 2020 at approximately 7:45am, the facility received a fax indicating a medication change to AV's narcotic medication. The facility did not implement the change and AV received a second dose. On or about June 10, 2020, AV was found slumped over in his/her wheelchair and was sent out to the emergency room due to the accidental overdose. The facility failed to provide a safe medication administration system putting AV at risk for serious harm, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP20-00689 $375.00 fine assessed