Violation Details: 00105850-AP-080863

Records Request Print
Date
10/6/2020
Report number
00105850-AP-080863
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
The facility failed to provide a safe medication administration system by not adequately monitoring staff or medication systems, leading to systemic medication errors and a delay in discovering that residents were not receiving medications as ordered for a long time. Alleged Perpetrator #2 (AP2) was found to unsubstantiated in this case. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.