- Date
- 4/15/2023
- Report number
- 00261971-AP-217098
- 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 two different blood pressure medications, one to be given in the morning and the other in the evening. Facility documentation shows Alleged Perpetrator #2 (AP2) did not follow proper medication administration checks, as AP2 is documented to have given AV the morning blood pressure mediation both morning and evening and not giving the other medication at all 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.