- Date
- 9/1/2024
- Report number
- 00352172-AP-302492
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on facility staff to ensure h/h basic care, safety, and supervision requirements are met, including all medication management, ordering and administration. AV service plan dated on or about May 13, 2024 indicates AV has anxiety and feels stable when getting h/h medication consistently; AV has past experiences that make AV rely heavily on h/h medication; If AV’s medication is a little late, AV becomes very nervous; Staff are to notify management right away and management will follow up and determine the issue causing AV’s medication to be late; AV requires maximum staff assistance with medication management, including storing and receiving AV’s medications in a “safe and timely manner”. It was discovered that the physician on AV's documentation is incorrect, causing medication to not be reordered timely. AV was documented to have not received h/h medication from approximately September 1-3, 2024; all administration times are marked as “waiting for delivery” of the medication. On or about September 2, 2024, AV was documented to be crying and upset because s/he did not receive h/h behavioral health medication over the weekend. AV reports during interview with APS, this is not the first time the facility has run out of h/h medications; s/he woke up at night with a terrible nightmare or hallucination, and s/he is uncomfortable when not receiving h/h medication. Staff report back up plan is to send a resident to the ER to be "dosed" if facility is out of resident medication. The facility failed to have a supply of medication in stock sufficient to allow for the administration of a resident's medication according to medical orders, staff did not follow facility back up plan by sending AV to the ER to be "dosed" if facility is out of resident medication. The facility failed to follow AV service plan by not contacting and notifying management right away concerning AV's medication, The facility failed to administer medication as ordered, which is a violation of resident rights is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP25-00127 $500.00 fine assessed