Violation Details: 00237104-AP-194385

Records Request Print
Date
11/8/2022
Report number
00237104-AP-194385
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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), and (2)(b)(F)
Findings
The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV)s medication orders were administered as prescribed and documented in the Medication Administration Record (MAR). Documentation provided to the Department shows on multiple occasions on or around November 2022 through December 2022 AV had several missed doses of insulin, and/or medication administered but not documented. Documentation shows AVs blood glucose readings to be high and as a result AV was admitted to the hospital with Diabetic Ketoacidosis (DKA) on two separate occasions. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00296 $1013.00 fine assessed