Violation Details: 00386695-AP-337191

Records Request Print
Date
2/26/2025
Report number
00386695-AP-337191
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
411-054-0025(1)(a) and (b)
411-054-0055(1)(f)
Findings
On or about February 26, 2025, Alleged Perpetrator 2 (AP2) failed to dispense the correct medication to the Alleged Victim (AV) resulting in unreasonable discomfort to AV. Based on facility documentation and interviews, at time of incident, the AV had been given another resident's medication and had not been given his/her pain medication as ordered which resulted in the AV experiencing minor gastrointestinal discomfort. AP2's action is considered neglect of care which constitutes abuse. The facility is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. The facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules.