Violation Details: 00414125-AP-365345

Records Request Print
Date
12/9/2024
Report number
00414125-AP-365345
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)
Findings
The Alleged Victim (AV) relies on the facility for care and assistance with their medications. AV has a history of chronic pain requiring both scheduled and pro re nata (prn) pain medication. On or about February 7, 2025, a pain patch AV used consistently was discontinued and an order for a prn pain cream was started. According to an investigation, staff did not know that a prn pain cream was ordered and available so it was never offered to AV, resulting in ongoing pain left untreated and unreasonable discomfort to AV. The facility failed to provide a safe medication administration system, which is considered neglect of care and constitutes abuse.
Sanction
RCFCP26-00219 $1500.00 fine assessed