Violation Details: 00373227-AP-323604

Records Request Print
Date
12/17/2024
Report number
00373227-AP-323604
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: 411-054-0030(1)(f)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about December 17, 2024, Alleged Perpetrator #2 (AP2) failed to pass 8PM medications due to AP2 not adjusting the medication administration system to match the correct shift. AP2 failed to reach out for assistance once that error was discovered. AP2 was trained in the medication administration management system and shift change procedure. AP2’s actions are a violation of resident rights, considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system and provide oversight to AP2 which violates Oregon Administrative Rules.