Violation Details: 00424083-AP-375569

Records Request Print
Date
8/24/2025
Report number
00424083-AP-375569
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
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)
Findings
The Alleged Victim (AV) relied on the facility for care and medication administration. According to an investigation, there were multiple medication and documentation errors in AV's pain patch administration by multiple facility staff between August 6, 2025, and August 15, 2025. On or about August 12, 2025, AV displayed out of character aggravation and irritation after missing their fentanyl patch change scheduled for that day. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP26-00409 $500.00 fine assessed