Violation Details: 00355931-AP-306269

Records Request Print
Date
9/17/2024
Report number
00355931-AP-306269
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)(f)
Findings
On or about September 17, 2024, Alleged Perpetrator 2 (AP2) did not give Alleged Victim (AV) a scheduled blood pressure, cognitive impairment, and heart medication during evening shift. Based on facility documentation and interviews, AP2 did not receive a complete training on medication administration. AP2's training documentation show 9 out of the 13 trainings were not completed prior to September 17, 2024. Medications are to be administered by trained staff, yet the facility placed AP2 on duty to pass medications on day of incident. AV experienced no adverse effects of missing medications; however, the facility failed to appropriately train AP2 to administer medication which resulted in AV not getting his/her medication as ordered. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. AP2 allegedly neglected AV. An investigation determined no abuse occurred by AP2.