Violation Details: 00407815-AP-358877

Records Request Print
Date
6/16/2025
Report number
00407815-AP-358877
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)
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 his or her care. On or about June 16, 2025, AV was in pain and did not receive ordered PRN pain medication, after previous given pain medications failed to provide relief. According to an investigation, the AV had a pain medication prescription since January 2025, but it was not filled by the pharmacy because it was incomplete. The Alleged Perpetrator 2 (AP2) did not follow-up to ensure the prescription was filled, leaving AV without access to pain medication. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. 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.
Sanction
ALFCP25-01086 $500.00 fine assessed