Violation Details: 00274388-AP-229019

Records Request Print Provider Details
Date
7/18/2023
Report number
00274388-AP-229019
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 to ensure The Alleged Victim’s (AV) medications were administered as ordered. On July 18, 2023, the facility identified an error with AV's antidepressant medication in which AV had been administered twice the daily dosage than what was prescribed since July 7, 2023. Based on interviews and facility documentation, the medication error caused AV to experience drowsiness and AV had several falls between July 11, 2023 and July 13, 2023, resulting in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00669 $375.00 fine assessed