- Date
- 10/31/2024
- Report number
- 00364494-AP-314762
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, on or about October 31, 2024, Alleged Perpetrator 2 (AP2) did not correctly input the order to stop AV’s pain medication, despite initialing the form that the order was processed and reviewed On or about November 2, 2024, Alleged Perpetrator 3 (AP3) initialed the form AP2 completed acknowledging the order to stop the medication had been input correctly. AV was given both the discontinued medication and new medication for approximately six days, posing a risk of harm. It was also discovered that multiple staff administered medications to AV, that were not in line with physician orders. AP2's and AP3’s actions are considered neglect and constitutes abuse. 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
- ALFCP25-00376 $375.00 fine assessed