- Date
- 2/26/2023
- Report number
- 00337294-AP-288206
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) had a condition which affects the pressure in his/her right eye. AV was prescribed medication for his/her right and left eye. On or about February 26, 2023, the facility received a prescription for AV's right eye to mitigate pressure in AV's eye. The facility has a three-step process to ensure medication orders are processed correctly. On or about June 6, 2024, it was discovered that AV had been receiving his/her eye medication into his/her left eye rather than his/her right eye. When the order was first sent, it was profiled incorrectly by the pharmacy but should have been caught by the facility, as the facility had previous errors with the pharmacy. Alleged Perpetrator #2 (AP2) was the last signatory on the order from February 2023 and did not catch the error. While AV did not have any lasting problems from not receiving the medication, AV could have lost his/her sight from not receiving this medication. AP2's failure is a violation of resident rights, is considered neglect of care and constitutes abuse as outlined in OAR411-020-0002(1)(b)(A)(ii). Respondent failed to ensure staff reviewed medication orders for errors to ensure residents receive proper medication as ordered. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
- Sanction
- ALFCP26-00302 $500.00 fine assessed