Violation Details: 00374493-AP-324852

Records Request Print
Date
12/18/2024
Report number
00374493-AP-324852
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), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0055(1)(a)(f) and (2)
Findings
The Alleged Victim (AV) has severe cognitive deficits and relies on the facility to administer his/her medications. According to an investigation, on or about December 18, 2024, and December 19, 2024, the Alleged Perpetrator 2 (AP2) failed to administer medication as ordered when he/she marked AV's medication administration record (MAR) as Lidocaine patch as administered. When the medication was counted on December 20, 2024, the patches had not been administered. This exposed AV to potential risk of serious harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medication was administered as ordered, which violates Oregon Administrative Rules.