Violation Details: 00266910-AP-221834

Records Request Print
Date
6/2/2023
Report number
00266910-AP-221834
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
411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
The facility failed to provide a safe medication administration system for Alleged Victim (AV). On or about June 2, 2023, the facility discovered that AV's liquid pain medication was not the right color. Instead of appearing bright blue, AV's liquid pain medication was a gray color and appeared a different texture. Based on facility documentation and interviews, it was determined that the facility failed to monitor that medication aides completed their job duties correctly to ensure accurate narcotic counts. The facility's failure put AV at risk of harm to receive medications that were tampered with which is a violation of resident rights, is considered neglect of care, and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined inconclusive findings.
Sanction
ALFCP23-00687 $375.00 fine assessed