Violation Details: 00371303-AP-321660

Records Request Print
Date
12/8/2024
Report number
00371303-AP-321660
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
411-05-0055(1)(f)
411-054-0025(1)(a) and (b)
Findings
On or about December 8, 2024, around 10:00 AM, Alleged Perpetrator 2 (AP2) administered Alleged Victim (AV) the wrong morning medications. AV is a resident of the facility. Based on facility documentation and interviews, as a result of AP2's medication administration error, AV experienced dizziness, lightheadedness, blurred vision, and low blood pressure. Although trained in proper medication administration, AP2 failed to perform required verification checks. AP2's actions caused physical harm and serious risk to AV, which is considered neglect of care and constitutes abuse. The facility also failed to maintain a safe medication administration system for AV, violating Oregon Administrative Rules.