Violation Details: 00330305-AP-281590

Records Request Print
Date
5/6/2024
Report number
00330305-AP-281590
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
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
Findings
The Alleged Victim (AV) relies on the facility for care and to provide a safe medication administration system. According to an investigation, on or about May 6, 2024, Alleged Perpetrator 2 (AP2) was working as a medication technician and administered the wrong medications to AV. AP2 was not to be passing medications without supervision as AP2 was new in the role. The facility did not have adequate staffing to allow another staff member to shadow AP2. The medication error was reported to staff by AP2, and AV was being monitored for the medication error by the facility. On May 7, 2024, AV suffered a fall due to being dizzy and was sent to the hospital. The facility failed to have a safe medication administration system, which is a violation of resident rights, is neglect which constitutes abuse. The allegation that AP2 was investigated and determined to be not substantiated.
Sanction
ALFCP25-00489 $375.00 fine assessed