Violation Details: 00354050-AP-304382

Records Request Print
Date
8/28/2024
Report number
00354050-AP-304382
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to have medication available
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)
Findings
On or about September 11, 2024, an audit was conducted by a facility nurse at which point it was discovered that AV missed medications that had been ordered by the ER on August 28, 2024. On or about August 28, 2024, AV was seen in the ER for shortness of breath and sent home with 2 different prescriptions for exacerbation. Upon return the same day, Witness 3 (W3) sent the after-visit summary noting new medications to the pharmacy via fax. On or about August 29, 2024, the pharmacy responded noting that the pharmacy could not dispense the medications because the faxed orders were unsigned. AV did not get the new medication until September 6, 2024 when AV's PCP provided an order during AV's follow up appointment. The facility failed to provide a safe medication administration system and administer medication as ordered which is a violation of Oregon Administrative Rules.