- Date
- 9/11/2021
- Report number
- 00159787-AP-126794
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On or about September 11, 2021, Alleged Perpetrator #2 (AP2) was passing medications to residents. The Alleged Victim (AV) is scheduled to receive medications. AP2's medication pass to AV was the incorrect medication for AV, which caused a reaction for AV including lethargy, sedation, shaking and slurred speech. AV was sent to the hospital for evaluation. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.