Violation Details: 00408408-AP-359456

Records Request Print
Date
6/17/2025
Report number
00408408-AP-359456
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
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
Alleged Victim’s (AV’s) care plan indicates that the facility is responsible for AV’s medication management. AV did not receive AV’s prescribed Xifaxan from June 1st to June 11, 2025. AV missed five (5) doses of Lactulose from June 5, 2025, to June 9, 2025. There is no documentation of AV being put on alert charting or increased monitoring due to running out of AV’s Xifaxan medication from June 1, 2025, to June 11, 2025. The facility did not note attempts to refill AV’s Xifaxan until June 7, 2025. The facility could not explain why the contact to the pharmacy and PCP was not made until June 7, 2025, when AV ran out of medication on June 1, 2025. As a result, AV was sent to the hospital on June 11, 2025, due to showing signs of possible stroke. Respondent failed to provide a safe medication administration system, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00254 $188.00 fine assessed