Violation Details: 00357018-AP-307339

Date
9/24/2024
Report number
00357018-AP-307339
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 (AV) relies on the facility to administer his/her medications. On or about September 22, 2024, AV moved into a new facility. AV’s insulin medication was transferred from AV’s old facility to AV’s new facility. Alleged Perpetrator 2 (AP2) was given AV’s new medication, however, AP2 only placed the medication on a counter, and it was later discarded. AP2 had marked that AV’s insulin, and all of his/her medication had not arrived, however, AP2 did not notify management that AV’s insulin was not present and did not contact hospice to get more insulin. On or about September 24, 2024, it was discovered that AV’s insulin was not present. AV had missed his/her morning dose of medication without any action being taken. On or about the evening of September 24, 2024, AV had a blood sugar of 503. AP2 failed to provide a safe medication administration system for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP25-00209 $250.00 fine assessed