Violation Details: 00408771-AP-360091

Records Request Print
Date
6/4/2025
Report number
00408771-AP-360091
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate 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
According to the documentation, the facility failed to provide a safe medication administration system by not administering the Alleged Victim’s (AV) anti-coagulation medication for approximately 13 days. From approximately May 23, 2025, through June 04, 2025, the AV’s anti-coagulation medication was not put into the medication administration record appropriately which did not notify medication technicians to administer the medication. The pharmacy delivered the medication to the facility on or about May 24, 2025. The failure to administer the AV’s anti-coagulation medication increased their risk of stroke, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP25-00482 $188.00 fine assessed