Violation Details: 00407198-AP-358262

Records Request Print
Date
6/12/2025
Report number
00407198-AP-358262
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 Alleged Victim (AV) relies on the facility for care and assistance with their medications. On or about June 5, 2025, AV's physician ordered a dosing change to AVs medication that is used to treat severe and persistent mental illness. According to an investigation, the facility did not follow their three-step process, and even though the order was marked as “pending confirmation” no one at the facility followed up to get the issue resolved timely. Between approximately June 5, 2025, and June 12, 2025, AV missed approximately 14 doses of the medication, resulting in AV exhibiting negative symptoms related to their severe and persistent mental illness, repeated unreasonable discomfort and emotional harm. The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered, which is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-01125 $1500.00 fine assessed