Violation Details: 00296355-AP-257094

Records Request Print
Date
11/11/2023
Report number
00296355-AP-257094
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: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on the facility to administer his/her medication. On or about November 11, 2023, Alleged Perpetrator 2 (AP2) made a medication error by not following proper procedure which caused the error. However, the wrong medication was still administered to AV. AP2 was trained on the medication cart on all the procedures and how to distribute medications. AP2 failed to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administration Rules.