Violation Details: 00247890-AP-203867

Records Request Print
Date
2/16/2023
Report number
00247890-AP-203867
Type
Abuse: Neglect
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: 411-054-0025(1)(a) and (b)
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 for a safe environment and care with management of medications. AV has history of Congestive Heart Failure (CHF), and hospitalization for treatment of exacerbated CHF, and fluid retention. AV’s medication was misfiled by the facility, and AV missed his/her daily dose of medication from approximately February 18, 2023, to approximately February 24, 2023. AV did not receive the medication as ordered and was placed on alert charting and had no side effects related to missed medications. The facility failed to provide a safe medication administration system to ensure the AV’s medication was administered as ordered, which is a violation of Oregon Administrative Rules.