- Date
- 11/29/2023
- Report number
- 00299625-AP-253036
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is a resident and under the care of this facility. On or about November 28, 2023, AV was prescribed a pain patch by AV's medical community partner to determine if AV's behaviors were caused by pain. The facility dispensed one pain patch which fell off and another patch was not dispensed or applied to AV. Based on facility documentation and interviews, facility staff requested clarification as to why the pain patch was ordered when AV had not indicated AV was in pain at any time. Facility staff were directed to not apply a second pain patch after the initial one fell off of AV. The facility contacted AV's primary care physician (PCP) for clarification of the order knowing AV was under the care of AV's medical community partner and all medication questions were to go through the medical community partner and not through the PCP that facility staff contacted. The facility has a responsibility to dispense medications as ordered by medical community partner. The facility's failure to dispense AV's pain patch as ordered as well as not following the order resulted in unreasonable discomfort, which is considered a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) is an employee of this facility and assists indirectly with AV's care. AV's service plan requires interventions/assistance with medication management resulting in the facility dispensing medications. AP2 refused to have staff follow AV's doctor's order for the pain patch to be dispensed and attempted to contact PCP via email, fax, and phone call without success to attempt to discuss the pain patch order. All medical contact should go through community partner as per community partner documentation. AV's community partner did not receive a request to review AV's medications from AP2. AP2 contacted AV's family, and a meeting was arranged. After the meeting, it was decided to dismiss AV's current primary care physician and bring in a new primary care physician who discontinued AV's pain patch. Based on facility documentation and interviews, AP2 stated the order for AV's pain patch was too extreme as AV had no prior use of pain medication. AP2 requested overdose medication due to concerns of AV receiving the pain patch. AV did not show signs/symptoms of oversedation due to the pain patch being applied/dispensed. AP2 instructed staff to not dispense AV's pain patch as order. AP2's actions of not following the order resulted in unreasonable discomfort to AV which is considered neglect of care and constitutes abuse. Based on facility documentation and interviews, Alleged Perpetrator 3 (AP3) put a hold on AV's pain patch indicating the pain patch was not to be dispensed as ordered. AP3 requested clarification on the order for the pain as AP3 did not agree with the order or dosage. AV's medical community partner was providing oversight of AV's care, and all medication orders/questions were to be completed through the medical community partner. AP3 instructed staff to not dispense AV's pain patch as ordered. AP3's lack of following the order resulted in unreasonable discomfort for AV which is considered neglect of care and constitutes abuse. An unknown Alleged Perpetrator 4 (AP4) allegedly financially exploited AV. An investigation inconclusively determined no abuse occurred by AP4.
- Sanction
- RCFCP24-01211 $500.00 fine assessed