Violation Details: 00327545-AP-278943

Records Request Print
Date
6/23/2023
Report number
00327545-AP-278943
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: 411-054-0055(1)(a) and (f)
Findings
On or about June 23, 2023, the facility failed to have a safe medication administration system which resulted in Alleged Victim (AV) not receiving his/her medication that improves his/her kidney function as ordered. Based on facility documentation and interviews, Alleged Perpetrator 2 (AP2) placed a hold on AV's medication without written orders from AV's medical provider and did not complete the follow-up steps to remove the hold. The facility is responsible for ensuring adequate professional oversight of the medication administration system and to ensure AV's medication is carried out as prescribed. The facility's failure is violation of Oregon Administrative Rules. AP2 allegedly neglected AV. An investigation determined that AV did experience any physical negative effects due to missing significant doses of this medication. Therefore, abuse did not occur by AP2.