- Date
- 5/18/2024
- Report number
- 00331993-AP-283244
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Alleged victim’s (AV’s) care plan includes staff direction if AV’s CBGs are less than 70 and steps to take if AV is conscious or unresponsive. On or about May 18, 18, 2024, at around 8:00 AM, AV’s blood sugar was 38, staff gave AV 9 units of insulin and juice. When AV was rechecked at around 9:30 AM, AV’s blood sugar was 21. Staff tried giving AV more juice with sugar packets, but AV wouldn’t take it. AV was incoherent. The eMAR did not have the parameters for what to do when AV’s blood sugar is low; it only had parameters for greater than 400 CBGs. As a result, AV was sent to the ER due to his/her CBG’s levels. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP24-01127 $500.00 fine assessed