- Date
- 6/9/2023
- Report number
- 00274630-AP-254025
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On or about June 18, 2023, the Alleged Victim (AV) was transported to the hospital due to signs of unreasonable discomfort associated with shortness of breath. While hospitalized, AV was treated with an increased dosage of his/her prescribed diuretic medication to alleviate symptoms, as AV was found to have approximately 32 pounds of excess fluid, which was subsequently removed. AV returned to the facility on July 3, 2023, under hospice care. Based on facility documentation and interviews, AV had moved into the facility on June 10, 2023, approximately eight days prior to the hospitalization event. Based on facility documentation and interviews, Alleged Perpetrator 2 (AP2) failed to enter AV's diuretic medication into AV's MAR, which resulted in AV experiencing increased swelling and hospitalization shortly after AV admissions to the facility. AP2 was still in training when AP2 entered AV's medication into AV's MAR. AP2 was hired to work at the facility on April 18, 2023. The facility's new hire policy states new employees are considered in training while in their 90-day probationary period. There is sufficient evidence to indicate that AP2 failed to accurately transcribe AV's medication orders into their MAR, which resulted in AV not receiving his/her diuretic medication as ordered, which resulted in AV being hospitalized. However, as AP2 was still in their training/probationary period when the error occurred, the facility is ultimately responsible for AP2's actions. The facility failed to provide a safe medication administration system which caused AV unreasonable discomfort resulting in hospitalization. The facility's failure is a violation of resident rights is considered neglect of care which constitutes abuse.
As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.
Allegation Notes