- Date
- 5/20/2020
- Report number
- 00088109-AP-066076
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Alleged Victim (AV) requires the assistance of the facility to manage his/her medication. On or about May 18, 2020, AV received an order for a new medication for heath failure. The facility sent the prescription to the pharmacy who entered the medication into the EMAR system and the medication was started on or about May 20, 2020. The facility has a triple check system in place to make sure the medications are put into the EMAR system correctly. On or about June 9, 2020, it was discovered that the medication was put into the EMAR system incorrectly causing AV for miss one dose daily. On or about June 11, 2020, AV was admitted to the hospitals with acute chronic diastolic congestive heath failure and suffered chest pains and shortness of breath. AV passed away on June 15, 2020. 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
- RCFCP20-01200 $2500.00 fine assessed