Violation Details: 00135094-AP-106054

Records Request Print
Date
4/2/2021
Report number
00135094-AP-106054
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: 411-054-0027(1)(f)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about March 31, 2021, Alleged Perpetrator 2 (AP2) requested Alleged Victim (AV) be placed on Alert and medication held. Alleged Perpetrator 3 (AP3) failed to ensure AV was placed on Alert and medication placed on hold. AP3 administered medication to AV after the medication was placed on hold, placing AV at risk for harm. AP3’s actions are a violation of residents rights, are 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.