Violation Details: 00121020-AP-094054

Records Request Print
Date
1/16/2021
Report number
00121020-AP-094054
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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
On or about January 7, 2021, the Alleged Victim (AV) had a medication discontinued for the morning dose. An error occurred in the process of changing the medication administration system (MAR) and it didn't get changed. AV continued to receive the morning dose of the medication for approximately a week, placing AV at risk for serious harm. AV was sent to the hospital on January 16, 2021 and diagnosed with an overdose of the medication. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP21-02477 $1125.00 fine assessed