Violation Details: 00315687-AP-267918

Records Request Print
Date
1/23/2024
Report number
00315687-AP-267918
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
External site: 411-054-0070(9)(c)
Findings
The Alleged Victim (AV) was actively dying and was scheduled to receive narcotic medication 4 times a day and as needed for pain. On or about January 22, 2024, AV received his/her pain medication at 8:30 PM. AV did not receive his/her medication again until January 23, 2024, at 4:30 AM. There was a language barrier with night shift staff, which contributed to AV not receiving his/her medication as ordered. AV suffered unreasonable discomfort due to not receiving his/her narcotic medication as ordered. The respondent failed to ensure medications were administered as ordered, and ensure staff have sufficient communication and language skills to perform their duties and communicate with residents and staff. These actions constitute abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(i) .
Sanction
RCFCP26-00240 $500.00 fine assessed