Date: 10/25/2017
Report Number: OR0001386500
Allegation: Failed to provide a safe medication administration system
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Description: Resident 1 was admitted in 2014 with multiple diagnoses as indicated in the attached report. Resident received crushed medication and a Fentanyl patch. Resident received another resident's Fentanyl patch which had an increased dosage. The error was caught two days later after the patch was applied. While the resident was more lethargic evidence is inconclusive the lethargy was due to the patch or the infection the resident had as indicated by resident's lab work. A connection was unable to be made between the medication error and the resident death. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violation occurred.
Rule(s) Violated: 411-086-0110
411-086-0260
Result: Substantiated
Findings: The facility failed to provide the necessary care and services regarding medication administration per physician orders.