Violation Details: 00239400-AP-196309

Records Request Print
Date
1/3/2023
Report number
00239400-AP-196309
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious 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 (f)
Findings
Alleged Victim (AV) relies on the facility to administer his/her medication. Between December 8th through December 28th, 2022, AV received double the daily dose of a warfarin medication. On or about December 28, 2022, AV was transported to the ER and diagnosed with poisoning by warfarin. Alleged Perpetrator 2 (AP2) authorized a MAR with incorrect warfarin dosing instructions. AP2 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, which is a violation of Oregon Administrative Rules.