Violation Details: 00259126-AP-214593

Records Request Print
Date
4/21/2023
Report number
00259126-AP-214593
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: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about April 21, 2023, Witness 3 (W3) administered the wrong medication to Alleged Victim (AV) which caused AV to experience unreasonable discomfort due to AV feeling shaky, sweaty, weak, and nauseous as a result of the medication error. AV was transported to hospital for evaluation. Based on facility documentation and interviews, Alleged Perpetrator 2 (AP2) was training W3 at time of incident and was expected to oversee medication pass. AP2 left W3 while in training and did not oversee the medication pass. AP2's actions is considered neglect of care which constitutes abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.