Violation Details: 00290669-AP-244669

Records Request Print
Date
9/12/2023
Report number
00290669-AP-244669
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)
Findings
On or about September 12, 2023, Alleged Perpetrator 2 (AP2) administered the wrong medication to Alleged Victim (AV). Based on facility documentation and interviews, AV was observed to be completely drowsy as a result of the medication error and was taken the hospital for monitoring. AP2's actions caused AV unreasonable discomfort, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.