Violation Details: 00260173-AP-215349

Date
2/6/2023
Report number
00260173-AP-215349
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Findings
Alleged Victim (AV) relies on the facility to administer his/her medication. On or about February 6, 2023, during the evening medication pass, AV was given an incorrect dosage of insulin (23 units), when their order for evening insulin was three (3) units of insulin. As a result for AV receiving an incorrect dose of insulin, AV sustained an adverse reaction which required immediate medical attention and AV being sent to the hospital. Alleged Perpetrator 2 (AP2) was asked to pass medication by the facility as they were short staffed in the evening, but AP2 was not fully trained by the facility as a medication technician until March 6, 2023. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP23-00611 $250.00 fine assessed