Violation Details: 00386964-AP-337455

Records Request Print
Date
2/19/2025
Report number
00386964-AP-337455
Type
Abuse: Neglect
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)(b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility for their care, including medication administration. According to an investigation, on or about February 19, 2025, during a medication audit the facility found AV's bottle of narcotic medication appeared to be replaced with water. The facility should have received a new bottle every 3 months. This specific bottle of medicine was open for 6 months. Liquid medicines in bottles were not checked for consistency, just that they were physically there in the med cart. The facility failed to a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
ALFCP26-00265 $250.00 fine assessed