- Date
- 9/11/2024
- Report number
- 00354328-AP-304669
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Findings
- Alleged Perpetrator #2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medications were administered as ordered. AP2 administered AV’s medication at the non-scheduled time despite updates to AV’s MAR. AP2 did not compare AV’s MAR to the narcotics logs showing amended time change for medication administration. AP2 administered AV’s medication at a previously scheduled time resulting in AV receiving a double dose of AV’s medication making AV feel dizzy. AP2 was notified by W1 of the error, AP2 admits to medication error. 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.