Violation Details: 00367765-AP-318066

Records Request Print
Date
11/19/2024
Report number
00367765-AP-318066
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)(a) and (f)
Findings
Alleged Victim (AV) is a resident of the facility who receives assistance with Activities of Daily Living, including medication administration. On or about November 19, 2024, Alleged Perpetrator 2 (AP2) was assisting AV with his/her medications. AP2 applied medication underneath AV's right eyelid. After AP2 applied AV's medication, AV noticed that AP2 incorrectly applied AV's topical skin medication instead of AV's eye medication. AV attempted to wipe away the topical skin medication and accidently got some of the medication into AV's eye. As a result of AP2's error, AV experienced a burning sensation and discomfort in AV's eye as a result of AP2's medication misadministration. Based on facility documentation and interviews, AP2 completed training for Administration of Eye/Drops/Ointments on November 12, 2024, and completed training for Medication Errors, and how to prevent errors on November 12, 2024. AP2's actions caused AV unreasonable discomfort which 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.