Violation Details: 00235526-AP-192983

Records Request Print
Date
12/3/2022
Report number
00235526-AP-192983
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: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (r)
Findings
Alleged Victim (AV) relies on the facility to administer his/her medication. On or about December 3, 2022, AV went to the med cart and requested his/her PRN medication for nausea. Alleged Perpetrator 2 (AP2) made an error by administering a medication for antipsychotic/antiemetic that was not prescribed to AV. AP2 stated that the med error was his/her fault; AP2 deviated from protocol and did not check AV’s MAR for available PRN medications first. As a result of the medication error, AV complained of a headache. AP2 failed to provide a safe medication administration system for AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe medication administration system, which is a violation of Oregon Administrative Rules.