Violation Details: 00365868-AP-316103

Records Request Print
Date
11/9/2024
Report number
00365868-AP-316103
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to administer medication as ordered
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: 411-054-0030(1)(f)
External site: 411-054-0036(2)(g)
External site: 411-054-0055(1)(a) and (b)
Findings
Alleged Victim (AV's) anticoagulant medication changes frequently based on AV's lab results. AV missed AV's anticoagulant medication on November 9, 2024. AV's medication update faxed to the pharmacy by staff. AV's pharmacy reported they did not receive the updated anticoagulant medication order. AV's risk of harm for missing one dose of anticoagulant medication a potential increase in bleeding and/or blood in AV's stool. The facility failed to administer AV's medication as ordered, which is a violation of Oregon Administrative Rules.