Violation Details: 00424228-AP-392962

Records Request Print
Date
9/2/2025
Report number
00424228-AP-392962
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to administer medication as ordered
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 their care, including medication management. According to an investigation, the facility received orders on or about September 16, 2025, for AV to receive a pain patch every 72 hours and to remove the old patch before applying the new one. The order was entered into system as “as needed” and approved by Alleged Perpetrator 2 (AP2). On or about October 9, 2025, AV was found with a pain batch dated “9/16/2025”, resulting in pain in AV’s back and legs. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medication was administered as ordered, which is a violation of resident rights, is neglect of care which constitutes abuse.
Sanction
RCFCP26-00147 $338.00 fine assessed