Violation Details: 00414514-AP-365762

Records Request Print
Date
6/26/2025
Report number
00414514-AP-365762
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
In July 2025, the facility experienced a breakdown in its medication management system, which directly affected an Alleged Victim (AV) under its care. Based on facility documentation and staff interviews, the facility failed to maintain a safe and accurate medication administration system. As a result, the Alleged Victim (AV) was administered a discontinued narcotic medication in addition to a newly prescribed narcotic medication which AV exhibited symptoms consistent with a drug overdose. AV experienced increased sedation that may have been a result of AV's medication not being administered as order. The facility’s failure to administer medications as ordered caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care, which constitutes abuse.
Sanction
RCFCP25-01138 $1500.00 fine assessed