Violation Details: 00406957-AP-358037

Records Request Print
Date
6/10/2025
Report number
00406957-AP-358037
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)
External site: 411-054-0055(2)
Findings
The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, on or about June 10, 2025, AV was given two medications that were discontinued and new medication. AV experienced side effects due to the medication error and was given Narcan by the EMT’s. It was discovered that the Medication Administration Record (MAR) had not been updated as there were no staff working who were trained on updating the MAR. The facility failed to provide a safe medication administration system, which is considered neglect of care and constitutes abuse.
Sanction
ALFCP25-01031 $1125.00 fine assessed