Violation Details: 00240972-AP-197751

Date
1/8/2023
Report number
00240972-AP-197751
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Findings
The Alleged Victim (AV) was on hospice care. On or about January 8, 2023, the Alleged Perpetrator #2 (AP2) was the medication technician on duty. On this day, AV needed his/her scheduled pain medication. AP2 was unaware of how to give this medication or how to correctly pull this medication for administration to AV. AP2 administered 2.5 ml of AV's narcotic medication instead of .5 ml as instructed on the medication record, placing AV at risk for serious harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility's failure to ensure staff are properly trained is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00282 $375.00 fine assessed