Violation Details: 00177346-AP-140898

Records Request Print
Date
12/1/2021
Report number
00177346-AP-140898
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
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
Alleged Victim (AV) relies on the facility to administer his/her medications. On or about November 21, 2021, AV went to the ER for altered mental status. AV was on (cognitive disease medication) at that time, which causes AV confusion. AV’s PCP cancelled that medication and changed to a different medication. On or about December 1, 2021, AV was discharged with orders to the facility for a medication change. On or about December 29,2021, AV returned to the ER with altered mental status again. The facility did not discontinue the (cognitive disease medication) which caused for AV to return to the hospital once again with altered mental status. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
RCFCP23-00918 $250.00 fine assessed