Date: 4/22/2017
Report Number: ES171029
Allegation: Failed to provide a safe medication administration system
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Description: Resident #1's physician orders indicated that his/her medication should be held and not administered when the systolic blood pressure is less than 110. On or about 4/21/17 The facility determined Resident #1's blood pressure was 107/69. The facility failed to hold the medication and administered it to Resident #1. The facility's failure to administer Resident #1's medications as prescribed is a violation of resident rights and the Oregon Administrative Rules.
Rule(s) Violated: 411-054-0027(1)(r)
411-054-0055(1)(f)
Result: Substantiated
Findings: The facility failed to maintain an adequate medication system.