Violation Details: 00170427-AP-135291

Records Request Print
Date
11/15/2021
Report number
00170427-AP-135291
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: 411-054-0027(1)(f) and (r)
External site: 411-054-0027(2)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on the facility to administer his/her medication. On or about November 14, 2021, while cleaning AV after finding medication ointment, staff found one of AV’s whole, uncrushed prescribed pain pills under his/her bed. The pill was given to the med tech, who did verify that it was one of AV’s. Alleged Perpetrator 2 (AP2) did not crush medication as mentioned in the Medication Administration Record (MAR). AP2 failed to provide to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to assure AV was provided a safe medication administration system, which is a violation of Oregon Administrative Rules.