- Date
- 10/2/2024
- Report number
- 00358396-AP-308754
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- According to the documentation, the Alleged Perpetrator 2 (AP2) missed new orders to hold blood thinning medication after the Alleged Victim (AV) was discharged from the hospital after being diagnosed with a brain bleed. On or about October 01, 2024, the AV suffered a fall and hit their head. They were taken to the hospital and were diagnosed with a small brain bleed. The AV was discharged back to the facility on or about October 02, 2024. At approximately 3:24 PM, the hospital faxed new orders to the fax number provided by AP2. The hospital also called and left a voicemail for the AP2 stating new orders were being sent via fax. AP2 did not make the changes to hold the AV’s two blood thinning medications on the MAR and staff administered these medications after the AV returned. On or about October 03, 2024, the AP2 found the new orders and noticed the staff had administered the blood thinning medication. The AP2 sent the AV back to the hospital and was diagnosed with a medium sized brain bleed. The administration of the blood thinning medication caused the AV’s condition to worsen and required medical intervention, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP25-00189 $375.00 fine assessed