- Date
- 11/4/2023
- Report number
- 00310792-AP-263427
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is alert to person, place, time, situation and is able to make h/h needs known. AV relies on facility staff to administer h/h medications as prescribed by h/h provider(s). In approximately October of 2023, AV had an order written by h/h PCP for doses of scheduled narcotic pain medication to be given at 8:00 am and 8:00 pm, and had an order written by h/h PCP for doses of PRN narcotic pain medication to be given as needed in addition to the two scheduled doses, not to exceed four tablets in one day. AV had been taking this narcotic pain medication for at least the past year prior to November 4, 2023. On or about November 4, 2023, Witness 2 (W2) asked Alleged Perpetrator 2 (AP2) for clarification regarding AV’s medication orders and the timing of the doses of narcotic pain medication as W2 was unsure if the doses could be given close together. A fax was sent to AV’s PCP requesting clarification and additional parameters for the narcotic pain medication orders. The fax was sent on a Friday, and the order clarifications from the PCP were not received by the facility until the following Monday. AP2 directed the med-techs that there had to be at least 4 hours between when the scheduled dose of narcotic pain medication and the PRN dose of narcotic pain medication were given. AP2 stated that this decision was put into place by h/h based on “normal spacing” as s/he knew them from h/h education. The facility was unable to produce a policy or guidelines that stated what the required parameters for narcotic prescriptions are. AV received no doses of PRN narcotic pain medication between November 4, 2023 and November 6, 2023. While awaiting the order clarification AV experienced trouble sleeping due to increased pain, experienced more shaking than normal and needed additional staff assistance while transferring.
AP1 and AP2 failed to administer AV PRN pain medication as prescribed, resulting in pain and unreasonable discomfort The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP24-00789 $250.00 fine assessed