Violation Details: 00269559-AP-224433

Records Request Print
Date
4/3/2023
Report number
00269559-AP-224433
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication orders were administered as prescribed. AV has history of multiple previous strokes. Facility staff are responsible for ordering, storing, and administrating AV's medications. According to Interviews and documentation provided to the department, AV was not administered Lisinopril as scheduled from approximately April 03, 2023, through June 20, 2023, resulting in AV experiencing elevated blood pressure, stroke like symptoms and being transported to the emergency room twice. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00733 $375.00 fine assessed