- Date
- 11/5/2025
- Report number
- 00440468-AP-392341
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On or about November 17, 2025, the Alleged Victim (AV) was hospitalized and diagnosed with an acute kidney injury (AKI) requiring dialysis. According to the medication list received from the facility at time of admission, AV was receiving a diuretic (20 mg daily), an ACE inhibitor (40 mg daily), and a weight-management injection (0.25 mg). Based on facility documentation and interviews, AV had a prior November 2025 hospitalization and at time of discharge on November 2, 2025, the hospital discontinued AV’s ACE inhibitor, diuretic, and weight-management medication. At time of AV's November 17, 2025, hospitalization, it was determined facility staff continued administering all three discontinued medications. The administration of discontinued medications negatively affected AV, resulting in AV being admitted to the hospital with concerns for AV’s kidneys. The facility’s failure to reconcile discharge medication orders, verify discontinuations, and ensure safe medication administration directly contributed to AV developing AKI requiring hospitalization and dialysis which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP26-00356 $2500.00 fine assessed