- Date
- 11/17/2021
- Report number
- 00171134-AP-135965
- 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 Perpetrator 2 (AP2) made an error when he/she verified the information on Alleged Victim's (AV) medication doctor's order for AV's blood pressure. AP2's error was not discovered until the facility sent for a medication refill. An investigation determined that AV received the doubled dose of his/her blood pressure medication due to AP2's error from September 22, 2021 through November 17, 2021. AP2's action is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.