Violation Details: 00115850-AP-089591

Date
11/18/2020
Report number
00115850-AP-089591
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 Tramadol and Oxycodone for pain receive. On or about November 18, 2020, 11 of AV’s prescribed Tramadol tablets and 61 of AV’s prescribed Oxycodone tablets were reported unaccounted for. Alleged Perpetrator 2 (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
ALFCP22-00991 $500.00 fine assessed