- Date
- 10/24/2024
- Report number
- 00362439-AP-312695
- 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
-
- Findings
- According to the documentation, the Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) failed to provide a safe medication administration system for the Alleged Victim (AV). On or about October 24, 2024, AP2 was training the AP3 on medication pass. AP2 handed AP3 a cup of meds to administer to the AV. AP3 did not double check the medication’s handed to them by AP2 were in fact the medications of the AV. AP3 administered the medication to the AV. After the wrong medications were administered, AP3 realized the medications were not correct but it was too late. Administrative staff were immediately notified and the AV was sent to the ER for monitoring in case the AV experienced serious side effects. The failure to provide a safe medication administration system to the AV placed them at a risk of harm, which is a violation of resident rights, is 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.