- Date
- 3/2/2024
- Report number
- 00322508-AP-274306
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Findings
- Alleged Victim (AV) self-administers some medication but will have all medication ordered through AP1's pharmacy. AP1 staff are instructed to reorder medication within seven days of last dose availability. In March 2024, AP1 staff failed to reorder AV's PRN medication for breathing in a timely manner. AV's medication was typically only used two times a day, staff collectively failed to place a reorder request until March 8, 2024. When the reorder was placed, additional pharmacy follow-up was required. AV had begun using the medication more frequently, and AV ran out of medication completely. Every staff person working on the medication cart is responsible for ordering medications and following up timely with requests. However, AP1 had multiple staff working on the cart who did not have pharmacy log-in capabilities. AV running out of h/h medication resulted in a visit to the emergency room (ER) for shortness of breath. AP1's training is clear that refills must be reordered before medication reaches a 7-day supply, however due to a collective facility failure to follow this protocol, AV ran out of medication and experienced an increase in shortness of breath resulting in a visit to the ER for shortness of breath, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP24-01130 $500.00 fine assessed