Violation Details: 00232276-AP-190179

Records Request Print
Date
11/16/2022
Report number
00232276-AP-190179
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)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and f)
Findings
The facility was implementing a new computer-based MAR system on or around October 2022. On or about November 16, 2022, Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) administered Alleged Victim (AV) medication belonging to another resident, causing his or her blood sugar to drop and exposing risk of serious harm to AV. The allegation that AP2 and AP3 failed to provide a safe medication administration system was investigated and the determination was not substantiated. The facility failed to provide a safe medication system which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP23-00288 $188.00 fine assessed