Violation Details: 00296815-AP-250438

Records Request Print
Date
9/24/2023
Report number
00296815-AP-250438
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: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on the facility to administer his/her medication. On or about September 13, 2023, AV’s medication #1 was discontinued by AV’s doctor. Staff checked AV’s faxed doctor’s order and did not catch that medication #1 was discontinued. Between September 13th, through September 24, 2023, AV was administered medication #1. As a result, for AV being over medicated, AV was admitted to the hospital on or about September 24, 2023, with a gastrointestinal bleed. One of the side effects of taking too much medication #1 is gastrointestinal bleeding. The facility failed to provide a safe medication administration system for AV, placing AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
RCFCP24-00338 $500.00 fine assessed