Violation Details: 00332633-AP-283799

Records Request Print
Date
5/21/2024
Report number
00332633-AP-283799
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 May 20, 2024, Alleged Perpetrator 2 (AP2), was preparing resident medications for morning rounds. AP2 noticed that Alleged Victim (AV) had two bottles of the same medication for blood pressure. AP2 observed one bottle was full and the other bottle was almost empty. AP2 then combined the two bottles to save space. AP2 discarded the empty bottle. AP2 then continued with medication distribution. Based on facility documentation and interviews, AP2 made an error when he/she combined AV's medication. AP2 combined AV's medication that deals with gout into the bottle of the medication that deals with blood pressure, mistaking it for the same medication. Facility staff administered what they thought was AV's medication that deals with blood pressure on May 21, 2024, but due to AP2's actions, it was unclear what the medication administered was actually for. AP2's actions placed AV at risk of harm which is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.