Violation Details: 00382608-AP-333076

Records Request Print
Date
2/7/2025
Report number
00382608-AP-333076
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), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility for care and medication management. According to an investigation, there was a duplicate medication order on the AV’s Medication Administration Record (MAR), resulting in the AV getting a double dose of a medication on at least two occasions. The facility failed to provide a safe medication administration system to ensure AV medications were given per physician orders, resulting in AV experiencing increased drowsiness/fatigue, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-00839 $375.00 fine assessed