Violation Details: 00136424-AP-107132

Date
4/26/2021
Report number
00136424-AP-107132
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. Between April 9, through April 14, 2021, AV was shorted one pill on three (3) separate occasions and did not receive a medication (anti-anxiety/sedative) as it was mis-written as a PRN (as needed) instead of PM (nightly). Between April 14, through April 30, 2021, more medication errors occurred, which included more errors in documentation where the facility initialed that a medication (antibiotic) was given on days when the medication was not available in the facility. 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
ALFCP22-00469 $500.00 fine assessed