Violation Details: 00141184-AP-111206

Records Request Print
Date
5/19/2021
Report number
00141184-AP-111206
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)(r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about May 14, 2021, the Alleged Victim (AV) had a medication change. All documentation was correct regarding the medication change, however, Alleged Perpetrator #2 (AP2) failed to catch the change and administered AV both medications on May 18 and May 19, causing AV's blood sugar to drop to 40, requiring AV to visit the hospital. AP2's actions are 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.