- Date
- 9/8/2023
- Report number
- 00285142-AP-239474
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) has a history of behaviors and takes medication to help alleviate these behaviors. On or about September 5, 2023, AV's physician faxed the facility and pharmacy new orders for two different types of medication for AV. On that same day, Alleged Perpetrator #2 (AP2) approved the changes without checking the original order. The pharmacy had accidentally discontinued one of AV's medications, which was not caught by AP2. Another staff should have completed the triple check of the medication, however, this was not completed. AV did not receive his/her medication for 3 days, which could cause AV to have behaviors that would place AV and others at risk for serious harm. AP2's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facilities failure to ensure proper oversight is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00080 $375.00 fine assessed