Violation Details: 00359003-AP-309338

Records Request Print
Date
10/6/2024
Report number
00359003-AP-309338
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: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about October 6, 2024, Alleged Perpetrator #3 (AP3) was training Alleged Perpetrator #2 (AP2) to pass medication to residents. AP3 instructed AP2 to give the Alleged Victim (AV) his/her medication. AP3 provided AP2 with three cups of pre-popped medication, however, did not tell AP2 which medication was for which resident. AP2 gave incorrect medication to AV, causing AV to feel dizzy. AP2's actions were found to be not substantiated. AP3's failure to ensure proper oversight of medication training, and allowing AP2 to provide incorrect medication to AV is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.