Violation Details: 00409731-AP-360818

Records Request Print
Date
6/5/2025
Report number
00409731-AP-360818
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), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0055(1)(a) and (f), 411-054-0070(2)(a)
Findings
Alleged Victim (AV) relies on facility staff to administer medications. According to an investigation, on or about, June 20, 2025, it was discovered that the AV had not received prescribed daily Lithium from 6/5/2025 through 6/22/2025. The Alleged Perpetrator 2 (AP2) did not administer the medication to AV, but had marked the medication administration record (MAR) as administered. AP2's actions exposed AV to risk of serious harm, are considered neglect and constitutes abuse. Based on the investigation, it was determined that the facility did not provide a safe medication administration system and did not provide required training to AP2, which is a violation of resident rights, is neglect of care which constitutes abuse. The allegation that the Alleged Perpetrator 3 (AP3) neglected AV was investigated and determined to be inconclusive.
Sanction
RCFCP25-01307 $500.00 fine assessed