- Date
- 1/27/2025
- Report number
- 00380540-AP-331055
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) was prescribed medication for wrist pain following a fall. The Alleged Perpetrator 2 (AP2) did not process and input the new physician order, therefore the AV was not given the medication. There was no observable or documented evidence of a negative outcome. The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered, which is a violation of Oregon Administrative Rules.