- Date
- 4/8/2025
- Report number
- 00393992-AP-344686
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. On or about August 7, 2025, AV told facility staff that he/she was feeling increased pain and discomfort. AV's medical provider was contacted due to AV's complaint which resulted in AV's medical provider sending a nurse to the facility to assess AV. The nurse reviewed AV's medications, and it was determined that AV's diuretic medication was not being administered as ordered. After consultation with the AV's medical provider, AV was administered a double dose of his/her diuretic medication. AV continued to experience pain, discomfort, and difficulty breathing. In the early morning hours of April 8, 2025, AV requested to be sent out to the hospital. AV was admitted to the hospital for worsening renal function, swelling, and discomfort. Based on facility documentation and interviews, AV was prescribed his/her diuretic medication on March 25, 2025. The order was not properly processed by facility staff and did not get added to AV's MAR. The delay in administering AV's diuretic medication resulted in unreasonable discomfort and continued pain lasting longer than 24 hours due to fluid retention symptoms. The facility's failure to provide a safe medication administration system for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP25-00266 $1500.00 fine assessed