Violation Details: 00392384-AP-342951

Date
3/15/2025
Report number
00392384-AP-342951
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Findings
According to the documentation, the facility failed to provide a safe medication administration system by not following parameters to hold the Alleged Victim’s (AV) blood pressure medication. During a medication audit, the person auditing the medications saw that staff were not following parameters set by the physician to hold the AV’s blood pressure medication when it was about 150. The MAR was changed to make it more clear to the medication technicians as when to hold the medication and when to administer it. The failure to provide a safe medication administration system put the AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP25-00187 $375.00 fine assessed