Violation Details: 00197179-AP-158188

Records Request Print
Date
4/27/2022
Report number
00197179-AP-158188
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: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about April 27, 2022, the Alleged Victim (AV) was given medication that belonged to another resident. Alleged Perpetrator #3 (AP3) was training Alleged Perpetrator # (AP2) when AP2 gave the incorrect medication to AV. AP3 noticed that AV had been given incorrect medication and notified AV's Physician and the facility Nurse. Staff monitored AV and noticed his/her blood pressure was very low. AV was sent out to the emergency department where he/she was diagnosed with accidental overdose and was given medication to increase his/her heart rate. AP3's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00097 $375.00 fine assessed