- Date
- 1/14/2026
- Report number
- 00451156-AP-403135
- 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 January 14, 2026, the facility failed to provide adequate oversight of its Medication Administration System, resulting in harm to the Alleged Victim (AV). AV was a resident of the facility, requiring full assistance with his/her care needs. On January 3, 2026, AV experienced respiratory distress and low oxygen levels and was diagnosed with influenza. AV’s symptoms persisted, and on January 9, 2026, AV’s primary care provider prescribed multiple PRN respiratory medications. These medications arrived at the facility on January 10, 2026, were entered into AV’s MAR, and required Alert Charting due to being PRN. As AV continued to show signs of discomfort, staff did not administer the PRN respiratory medications despite AV exhibiting respiratory distress. Facility documentation and interviews confirm AV did not receive any of the prescribed PRN medications until January 14, 2026. The facility utilizes a “triple check system” for order verification, medication processing, MAR entry, and initiation of Alert Charting. At the time of the incident, only two staff members had medication-approval access, preventing timely processing of new orders. The facility’s failure to ensure timely administration of ordered PRN medications resulted in prolonged respiratory distress and discomfort for AV. This failure is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- RCFCP26-00361 $1500.00 fine assessed