Violation Details: 00333104-AP-284269

Records Request Print
Date
5/24/2024
Report number
00333104-AP-284269
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: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on the facility to administer his/her medications. On or about May 23rd and 24th, 2024, AV was administered (blood pressure medication #1) and (blood pressure medication #2). The order to discontinue (blood pressure medication #1) was misplaced and was located after AV had already received blood pressure medication #1 in error on or about May 23rd and 24th, 2024. As a result, AV had a fall on May 23rd and 24th, 2024, in which AV sustained injuries. AV’s primary care team discontinued both blood pressure medications due to AV having side effects and resulting in falls. 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
RCFCP25-00147 $500.00 fine assessed