- Date
- 7/27/2024
- Report number
- 00345598-AP-296054
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Findings
- The facility (AP1) manages all aspects of Alleged Victim's (AV's) medication management, including ordering and storing, and administration except for temporary use of a PRN narcotic pain reliever to be used after a recent surgery. AV is prescribed several medications including an antiarrhythmic, beta-blocker, anti depressant, acid-reducer, and anticoagulant. AV missed doses of each of these medications because AP1 staff did not have them available for AV. AV's medications are sent from the pharmacy in a cycle-fill. This means that staff responsible for ordering medications do not assume they need to manually reorder. Sometimes the pharmacy will need more information or documentation before the cycle-fill can be completed. This is typically communicated throughout checks and verifications completed weeks in advance. AV's provider was faxed for a new prescription only after AV had already missed doses of medication. AV missed multiple doses of multiple medications before this incident was corrected, which led to AV reporting to multiple people that AV was feeling unwell. On or about July 30, 2024, AV told staff that AV had tightness in h/h chest and nausea, and approximately on July 31, 2024, AV had a higher than typical blood pressure reading. AV has symptoms of head hurting and feeling restless, like s/he can't stop moving or talking. AV feels like s/he is having withdrawals from missing two consecutive days of h/h antidepressant. The facility failed to have adequate supply of AV medications and provide a safe medication system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP24-01132 $500.00 fine assessed