- Date
- 7/15/2022
- Report number
- 00210616-AP-170259
- 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 July 15, 2022, Alleged Perpetrator #3 (AP3) was training the Alleged Perpetrator #2 (AP2) in medication administration. AP2 was in their second day of training and was not yet deemed competent to pass medications alone. AP3 stepped away to assist another resident and AP2 administered another resident’s medications to the Alleged Victim (AV). AP3 failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. The failure resulted in desaturation of AV’s oxygen levels and AV was sent to the hospital for overnight observation. AP3’s actions are a violation of resident rights, is 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
- ALFCP23-00140 $375.00 fine assessed