Violation Details: 00462149-AP-414506

Records Request Print
Date
3/7/2026
Report number
00462149-AP-414506
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
411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility to administer his/her medications. According to an investigation, on or about March 7, 2026, AV did not receive narcotic pain medication as ordered. Between February 7, 2026, and March 6, 2026, AV was receiving the pain medication four times per day, instead of three times per day as ordered. On March 7, 2026, AV ran out of the medication. AV did not receive any of the narcotic pain medication between March 7, 2026, and March 11, 2026 (five days), resulting in ongoing pain and unreasonable discomfort. The medication order from the physician did not match the medication administration record (MAR) and the error was not identified until AV ran out of the medication. The facility failed to provide a safe medication system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
RCFCP26-00576 $1500.00 fine assessed