Violation Details: 00258591-AP-213891

Records Request Print
Date
2/25/2023
Report number
00258591-AP-213891
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
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on the facility for assistance with medications. AV service plan indicates (Same Gender) staff only to apply lotion/powered only to (body region). Approximately during the months of February and March 2023 AV was not provided topical medications by Alleged Perpetrator 2 (AP2) resulting in AV experiencing itchiness, soreness, and unreasonable discomfort. Based on an investigation, it was determined that the facility has no policy regarding applying topical, medications when only opposite gender staff are working, nor is it documented in AV MAR, Care plan or Progress Notes for medication administration when only opposite gender staff are working. The allegation that AP2 failed to administer medications as ordered, was investigated and the determination was not substantiated. The facility failed to ensure adequate supervision, training, and oversight of the medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00628 $250.00 fine assessed