- Date
- 3/11/2021
- Report number
- 00129186-AP-100799
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On or about March 11, 2021, it was discovered that one of the Alleged Victim's (AV) medications was never placed into the medication administration system (MAR). Alleged Perpetrator #2 (AP2) faxed the order to the pharmacy, however, AP2 was not responsible for placing the order in the MAR. AP2 was found to have not committed any abuse or wrongdoing in this case. There was a triple check system for medications, however, Alleged Perpetrator #3 (AP3) and Alleged Perpetrator #4 (AP4) all signed off on this order, however, it was never placed in the MAR nor was the medication given to AV, which placed AV at risk for harm. AP3 and AP4's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP21-02480 $375.00 fine assessed