- Date
- 5/15/2025
- Report number
- 00402698-AP-353623
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- The facility is responsible for administering the Alleged Victim’s (AV’s) prescribed medications. AV had a prescription for an anticoagulant medication to be administered twice daily. Per AV's physician order, the anticoagulant was to be held for 72 hours prior to a scheduled medical procedure, with instructions to resume the regular dosing schedule the day following the procedure. Documentation indicates that the anticoagulant medication was placed on hold on or about April 20, 2025. The procedure was performed on or about April 23, 2025. On or about May 15, 2025, while AV was having breakfast, AV’s family observed facial drooping. AV was transported to the emergency department, where it was determined that AV had experienced a stroke. Subsequent review revealed that AV had not received the prescribed anticoagulant medication from April 20, 2025, through May 13, 2025. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse. An investigation was conducted into the allegation that AP2 failed to ensure a safe medication administration system. The allegation was not substantiated.
- Sanction
- RCFCP25-01265 $500.00 fine assessed