- Date
- 9/12/2021
- Report number
- 00159894-AP-126866
- 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) relies on the facility to administer his/her medication. On or about September 12, 2021, Alleged Perpetrator 2 (AP2), went to administer AV’s daily dose of insulin. AP2 thought that AP2 had prepped the pen with 40 units of slow acting insulin but had prepped the fast-acting insulin. AV said, “that’s a lot don’t you think?”, AP2’ re-read the medication and realized the mistake he/she had made. AV was hospitalized due to the medication error. AP2’s failed to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which is a violation of Oregon Administrative Rules.