Violation Details: 00383405-AP-333896

Records Request Print
Date
2/12/2025
Report number
00383405-AP-333896
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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)(g)
External site: 411-054-0055(1)(f)
Findings
According to the documentation, the facility failed to provide a safe medication administration system by not administering the Alleged Victim’s (AV) insulin medication as ordered. On or about November 29, 2024, the AV experienced a significant change of condition, and their service plan was updated for medication administration. There were numerous staff members hired as medication technicians where were not delegated timely to administer injectable medications to the AV, leading to missed doses of insulin medication over the course of approximately a few weeks. The AV experienced hot and cold flashes, shakiness, night sweats and vomiting due to the missed doses, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP25-00220 $500.00 fine assessed