- Date
- 11/20/2020
- Report number
- 00115841-AP-089578
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility to administer his/her medication. AV was prescribed 0.5mL Morphine every four (4) hours for pain and 0.25mL Lorazepam every four (4) hours as needed for seizure disorder. On or about November 15, 2020, it was reported that 28.25mL of AV’s Morphine and 30mL of AV’s Lorazepam were missing. The facility did not have a system in place to audit narcotic books prior to November 14, 2020. AP2 assumed primary responsibility for medication administration, destroying medication as needed, ordering medication, and documenting in the NARC books. The facility did not have a system to audit narcotic books prior to November 14, 2020. AP2 and 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
- ALFCP22-01007 $500.00 fine assessed