Violation Details: 00392711-AP-343312

Records Request Print
Date
3/26/2025
Report number
00392711-AP-343312
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)
External site: 411-054-0027(1)(s)
Findings
According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system by giving the Alleged Victim (AV) the wrong medication. On or about March 26, 2025, the AP2 was still in training for medication pass with Witness 3 (W3). AP2 was supposed to wait to for W3 to witness AP2 give medications to residents. AP2 did not wait for W3 and gave medication to the AV without proper supervision. AP2 gave the AV another residents medication causing the AV’s heart rate. PCP was notified and gave parameters to send AV to the hospital if their heartrate dropped below 60. The AV’s heartrate dropped to approximately 52 and the facility staff transferred the AV to the hospital. The AP2 failed to provide a safe medication administration system for the AV which caused adverse side effects requiring medical observation, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.