- Date
- 9/5/2025
- Report number
- 00425175-AP-376726
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for their care. According to an investigation, on or about September 9, 2025, the facility received a call that AV was out of their prescribed pain medication, and it could not be refilled. Between September 5, 2025, and September 8, 2025, AV missed multiple doses of narcotic pain medication, resulting in pain over multiple days. A full audit of AV’s pain medications was conducted. The audit revealed discrepancies between the narcotic logbook and the electronic medication administration record. Narcotic logs show repeated extra doses administered outside scheduled times throughout July and August, far exceeding the prescribed schedule of one tablet every six hours. These unauthorized administrations occurred on numerous occasions, including multiple times per day during several weeks in August, causing AV’s medication supply to run out prematurely. Further review showed that Alleged Perpetrator 2 (AP2) was the only staff member documented as incorrectly administering the pain medication to AV. AP2 resigned unexpectedly on the same day this issue was discovered. Since the incident, there have been no further medication errors. AP2's actions are considered financial exploitation and constitutes abuse. The facility failed to provide appropriate services, relating to providing a safe medication administration system, administering medication as ordered, and keeping AV free from financial exploitation, which is a violation of resident rights, is neglect of care which constitutes abuse.