Violation Details: 00261746-AP-216836

Records Request Print
Date
4/30/2023
Report number
00261746-AP-216836
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 April 30, 2023, Alleged Victim (AV) did not receive his/her evening medication which resulted in AV being at an elevated risk of cardiovascular issues due to AV's health and preexisting condition. 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 medication pass on April 30, 2023. AP2 failed to come into the facility to assist with medication pass and failed to ensure AV's evening medication was 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.