- Date
- 4/15/2023
- Report number
- 00261962-AP-217090
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) was taking blood pressure medication that was discontinued on April 15, 2023. Facility documentation shows Alleged Perpetrator #2 (AP2) did not follow proper medication administration checks, as AP2 is documented to have given AV medication from April 15 to April 20. Alleged Perpetrator #3 (AP3) found out about the med errors, however, didn't notify leadership to ensure an investigation was completed and and ensure proper monitoring of affected residents. AP2 and AP3's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.