- Date
- 11/8/2025
- Report number
- 00437887-AP-389750
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On or about November 8, 2025, the facility failed to provide adequate oversight of its Medication Administration System, resulting in harm to the Alleged Victim (AV). AV, a full-assist resident for medication management, did not receive his/her prescribed PRN pain medication for approximately 12 days. Based on facility documentation and interviews, AV’s last documented administered dose was given on November 7, 2025, at around 3:45 AM. On or about, November 8, 2025, the facility faxed refill orders to AV's health care provider; however, the order was returned unsigned and had to be resent. Additional delays occurred when the provider indicated AV had a new PCP and the facility in the process of transitioning to a new in-house pharmacy. From November 8, 2025, to November 13, 2025, AV was without any supply of the PRN pain medication resulting in continued pain. The facility did not receive the refill until November 19, 2025, when administration finally resumed. The facility's failure to provide a safe medication system for AV, resulted in continued pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP26-00354 $1500.00 fine assessed