Violation Details: 00300707-AP-254021

Records Request Print
Date
12/4/2023
Report number
00300707-AP-254021
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)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) is prescribed a scheduled dose of pain medication of 10 mg and an as-needed dose of pain medication of 2.5 mg nightly. On or about December 4, 2023, it was discovered that Alleged Perpetrator 2 (AP2) distributed AV’s pain medication in the 2.5 mg dosage for the scheduled medication pass at 8:00 pm dose on the dates of December 1st, 2nd, 3rd, and 4th, 2023, in error. As a result of the medication error, AV experienced pain and medication withdrawal symptoms on or about December 5, 2023. AP2 failed to provide a 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 Administrative Rules.