Violation Details: 00280604-AP-235144

Records Request Print Provider Details
Date
8/18/2023
Report number
00280604-AP-235144
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
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is prescribed medication for a heart condition. AV went to his/her physician and his/her INR levels were 1.1 and should have been between 2.0 and 3.0. A review of the facility documentation showed that AV did not receive his/her medication 9 times. Alleged Perpetrator #2 (AP2) signed off that he/she gave the medication, however there were 9 pills left. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.