Violation Details: 00312466-AP-264904

Records Request Print
Date
2/8/2024
Report number
00312466-AP-264904
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)
External site: 411-054-0027(1)(g)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(f)
External site: 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility for medication administration. AV is scheduled to have a medication patch applied to him/her every three days. When one is applied, the existing one is to be removed. On or about February 6, 2024, Alleged Perpetrator #2 (AP2) was dispensing medication to AV. AP2 placed AV's medication patch as directed. AV had been very lethargic on February 7, 2024, missing medication administrations, and it was thought by staff that AV was just tired. On or about February 8, 2024, it was discovered that AV had two medication patches on him/her, one on his/her back and another on his/her shoulder, which was caused AV to be over medicated. AP2'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.