Violation Details: 00313799-AP-276880

Records Request Print Provider Details
Date
2/18/2024
Report number
00313799-AP-276880
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(r)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
On or about February 18, 2024, the Alleged Victim (AV) received medication that belonged to another resident. Receiving another resident's medication placed AV at risk for serious harm, including low heart rate, cardiac arrest and serious bleeding. The facility failed to contact AV's primary care physician regarding this error, placing AV at risk for serious harm. The facility's failure to ensure AV's physician was contacted placed AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP24-00630 $250.00 fine assessed