Violation Details: 00089973-AP-067593

Records Request Print
Date
6/25/2020
Report number
00089973-AP-067593
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious 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) was to receive a patch every morning to help with behaviors. AV was experiencing increased behaviors and it was noted that AV was found with two patches attached to him/her, causing staff to check the medication and it was discovered that there were excess patches, showing that AV had not been receiving patches as ordered. Alleged Perpetrator #2 had marked the Medication Administration Record (MAR) that he/she had given the medication every day, but later admitted that he/she did not give AV his/her patch every day. AP2's action placed AV at a risk for serious harm, 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 violates Oregon Administrative Rules.