- Date
- 4/30/2023
- Report number
- 00261542-AP-216659
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On April 30, 2023, Alleged Victim (AV) did not receive his/her evening medications which put AV at risk of suffering from a blood clot and poor heart function. Per AV's physician, AV's evening medications are important to AV's heart health and should not be missed. Based on interviews and facility documentation, Alleged Perpetrator 2 (AP2) was responsible for maintaining appropriate staffing levels and was the on-call staff member at time of incident. AP2 was contacted by facility staff regarding the lack of medication aid to pass medication for the 8pm medications pass on April 30, 2023. AP2 failed to come into the facility to assist with medication pass and failed to ensure AV's evening medications were administered as ordered. AP2's actions is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) was at the facility from approximately 8pm until 9:30pm. AP3 was made aware of the lack of staff to pass medication on April 30, 2023, and declined to assist with medication administration. AP3's actions is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules.