Violation Details: 00388719-AP-339213

Records Request Print
Date
2/24/2025
Report number
00388719-AP-339213
Type
Licensing Violation
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: 411-054-0036(2)(g) and 411-054-0055(1)(a) and (f)
Findings
On or about February 24, 2025, the Alleged Victim (AV) was given 200 mg of medication when he/she was only to be given 50 mg of medication. Alleged Perpetrator #2 (AP2) administered AV's medication incorrectly, placing AV at risk for harm, as AV's physician indicated that AV is a fall risk, although AV is not care planned as a fall risk. This additional medication could have caused AV to become unsteady and suffer a fall. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure a safe medication administration system was determined to be inconclusive.