Violation Details: 00374495-AP-324856

Records Request Print
Date
12/18/2024
Report number
00374495-AP-324856
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 Rivastigmine having been administered when AP2 had not administered the medication. The Rivastigmine medication was counted on December 20, 2024, and showed the medication had not been administered as ordered. This exposed AV to potential risk of serious harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.