- Date
- 5/12/2023
- Report number
- 00262758-AP-229252
- 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. When AV moved into the facility, AV’s PCP was not available and no hold orders for AV’s insulin were obtained from the doctor. The facility should have pursued getting a doctor’s order for this when the doctor became available. Typically, the short-acting insulin would be held if the blood sugar was at or below 70, long-acting insulin should not have been held. Staff have been confused about the insulin administration and have been holding AVs scheduled long-acting insulin. As a result of the unclear directions for insulin administration, AV has been hospitalized related to blood sugars many times, putting AV in risk of serious harm. The facility to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP23-01208 $500.00 fine assessed