Violation Details: 00317030-AP-269098

Records Request Print
Date
3/5/2024
Report number
00317030-AP-269098
Type
Abuse: Neglect
Level
4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered by failing to have an accurate medication management system in place to correctly administer AV's medication and train staff. Based on facility documentation and interviews, AV did not get his/her diuretic prescription for several days. The medication error resulted in AV suffering shortness of breath, weight gain, edema in legs and abdomen, neck vein distention, and difficulty walking. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.
Sanction
RCFCP24-00855 $1500.00 fine assessed