Violation Details: 00365600-AP-340822

Records Request Print
Date
11/10/2024
Report number
00365600-AP-340822
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about November 21, 2024, the Alleged Victim (AV) was administered the incorrect amount of medication, placing AV at risk for harm. On this same day, AV's anti-coagulation clinic faxed a new order for half the amount of medication to be administered. The facility did not check the fax machine timely and missed the change to AV's medication, and administered the higher amount of medication, placing AV at risk for harm. The facility's failure to ensure a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP25-00158 $375.00 fine assessed