Violation Details: 00368059-AP-318461

Records Request Print
Date
11/21/2024
Report number
00368059-AP-318461
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)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about November 21, 2024, Alleged Perpetrator #2 (AP2) was administering medications and preparing to administer medication to the Alleged Victim (AV). AP2 as interrupted by other residents requesting medication and assisted them before returning to AV. Once AP2 administered medication to AV, he/she immediately realized he/she gave the incorrect medication to AV. AP2 immediately notified AV and the RN. AV was sent to the hospital where AV suffered from vomiting and disorientation. AP2's failure to ensure a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure is a violation of Oregon Administrative Rules.