Violation Details: 00320947-AP-272820

Records Request Print
Date
3/13/2024
Report number
00320947-AP-272820
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) and (s)
External site: 411-054-0028(1)(a) and (b)
External site: 411-054-0030(f)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to Alleged Victim (AV). AP2 did not clarify the medication order prior to faxing them to AV's pharmacy, AV's medication was discontinued, the original ordered was a PRN. When AP2 re-ordered the medication it was written as a scheduled medication. AV suffered three falls in a 24-hour period after receiving four doses of a medication. AP2's actions are 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.