- Date
- 11/8/2025
- Report number
- 00438000-AP-389813
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Based on witness statements, investigator observations, and documentary evidence, the investigator determined by a preponderance of the evidence that the facility failed to maintain an adequate supply of the Alleged Victim’s (AV’s) prescribed pain medication. As a result, AV did not receive the ordered medication from November 4, 2025, through November 10, 2025, because the medication was not available in the facility. On November 5, 2025, staff placed AV on alert charting due to the missing medication. Staff were instructed to monitor AV for increased pain, withdrawal symptoms, anxiety, agitation, sweating, chills, nausea, vomiting, diarrhea, muscle aches, back pain, joint pain, insomnia, and flu-like symptoms. Despite this, the facility did not obtain the required medication in a timely manner, and AV continued without the prescribed treatment. On November 8, 2025, AV was transferred to the hospital for evaluation. The investigation determined that the facility failed to maintain a safe and reliable medication administration system to ensure AV received medications as ordered. This failure resulted in unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care, which constitutes abuse.
- Sanction
- RCFCP26-00279 $1500.00 fine assessed