Violation Details: 00396002-AP-346696

Records Request Print
Date
4/3/2025
Report number
00396002-AP-346696
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)
External site: 411-054-0055(1)(a) and (f)
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 April 3, 2025, AV's physician ordered a medication to treat depression to be stopped and a lower dose of the same medication was ordered to effectively taper AV off the medication. According to an investigation, the order to stop the medication was processed by the facility, but the lower dose order was not. AVs medication was stopped "cold turkey" and between approximately April 4, 2025, and April 11, 2025, AV did not receive any of the medication, resulting in AV exhibiting aggressive behaviors, repeated unreasonable discomfort and emotional harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-01121 $500.00 fine assessed