- Date
- 9/21/2025
- Report number
- 00428432-AP-380118
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility to manage their medications, including insulin injections. The AV was prescribed long-acting insulin before bed and had an order for short-acting insulin that was on hold. According to an investigation, on or about September 21, 2025, the AV did not have enough long-acting insulin for their evening dose. Alleged Perpetrator 2 (AP2) did not follow proper procedure for medications and gave the AV their short acting-insulin. AP2 did not notify management of the medication error. The AV had a negative reaction and required hospitalization to address their blood sugars. AP2’s actions are a violation of resident rights, considered neglect, and constitute abuse. The facility failed to ensure a safe medication system by not ordering the AV's medications timely, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.
- Sanction
- ALFCP26-00004 $375.00 fine assessed