- Date
- 2/19/2019
- Report number
- 00072170-AP-052743
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is on a bowel regiment which includes scheduled and as needed medications for constipation/diarrhea. There are orders for the facility to administer Milk of Magnesia after no bowel movement for two days/48 hours, and then a stool softener can be given four (4) hours after this if not effective. On or about February 18, 2019, bowel charting shows that AV had a bowel movement at the end of the day. On February 19, 2019, AV was administered Milk of Magnesia and the stool softener in error. There were no documented side effects from the outcome of the bowel medications. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.