Violation Details: 00041822-AP-029388

Records Request Print
Date
7/25/2019
Report number
00041822-AP-029388
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate 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: 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) experienced side effects from being given 2 times the amount of morphine as ordered. On or about July 25, 2019, Alleged Perpetrator #2 (AP2) gave AV 2 times the amount of morphine as ordered, as he/she had popped the medication, left the medication room to attend to something else and when returned, popped two more morphine for the resident and administered the medication. AP2 failed to administer medication as ordered, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.