Violation Details: 00411062-AP-362201

Records Request Print
Date
6/29/2025
Report number
00411062-AP-362201
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, to include medication administration. AV has a history of seizures and it is documented that AV had a seizure previously when their antiseizure medication was attempted to be tapered by their physician. Between approximately June 27, 2025 and June 29, 2025, AV did not receive a scheduled antiseizure medication, due to it the order being marked as pending discontinuation. According to an investigation, no one checked to see if the physician was discontinuing the order or why it moved to pending status, until after the AV suffered a medical emergency and went to the hospital on June 29, 2025. The facility failed to provide a safe medication administration system to ensure Alleged Victim’s (AV) physician orders were followed, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP25-01390 $1125.00 fine assessed