- Date
- 10/25/2023
- Report number
- 00295390-AP-249138
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) anticoagulant medication was administered as ordered. On October 25, 2023, the facility received updated physician orders for AV's anticoagulant medication. Based on documentation and interviews, AV's new physician order was not implemented by the facility resulting AV experiencing shortness of breath and chest pain on or about October 27, 2023. AV was sent to the hospital for treatment. The facility's failure put AV at risk of experiencing a stroke, causing unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP24-00094 $1500.00 fine assessed