Violation Details: 00445797-AP-397804

Records Request Print
Date
11/14/2025
Report number
00445797-AP-397804
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about November 14, 2025, Alleged Perpetrator 2 (AP2) discontinued Alleged Victim's (AV) routine calcium channel blocker, and AV did not receive this daily medication from November 14, 2025, to December 15, 2025. Based on facility documentation and interviews, AP2 discontinued AV's medication in error due to reading AV's electronic medication administration record (EMAR) incorrectly. AP2 did not communicate in AV's communication log that AP2 discontinued this medication. AV experiences lower kidney functioning and not taking this medication as ordered put AV at elevated risk for cardiac event and/or increased risk of kidney damage or failure. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide adequate oversight of the facility's Medication Administration System which placed AV at risk of moderate harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP26-00164 $1013.00 fine assessed