Violation Details: 00380965-AP-335499

Records Request Print Provider Details
Date
1/26/2025
Report number
00380965-AP-335499
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
411-054-0025(2)
411-054-0027(1)(g) and (s)
411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) had a history of wandering the community and exit seeking. AV was chemically sedated by the facility staff with medication causing AV to sleep more than usual. After a meeting with the facility, it was discovered that at some point at the end of 2024, the facility had switched AV’s scheduled behavior medication to PRN. The medication change had not been approved by AV’s doctor. In January 2025, AV was given PRN pain medication on 7 different occasions on top of his/her scheduled pain medication which was 3 times a day. In January 2025, AV was given PRN anxiety/behaviors medication 8 different occasions on top of his/her scheduled medication which were 3 times a day. The facility failed to provide a safe medication administration system for AV, which put AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
RCFCP25-00708 $1501.00 fine assessed