Violation Details: 00393515-AP-344153

Records Request Print
Date
4/2/2025
Report number
00393515-AP-344153
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)(a) and (f)
Findings
The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AV was given another resident's medication in addition to the AV's prescribed medication. This error was done by a staff member in training. AV was observed to have no adverse side effects or any deviation from baseline, there was also no deviation from AV's daily routine as a result of the error. However, the facility did fail to provide a safe medication system which is a violation of Oregon Administrative Rules.