Violation Details: 00438029-AP-389839

Records Request Print
Date
8/14/2024
Report number
00438029-AP-389839
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
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s): 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
External site: 411-054-0070(2), (5)(b)(G)
Findings
The Alleged Victim (AV) receives his/her medication from facility staff. On or about August 14, 2024, AV was given incorrect medication that belonged to another resident by Alleged Perpetrator #2 (AP2). AP2 realized his/her error and advised another staff. AV was sent out to the hospital for evaluation where he/she suffered drowsiness and ultimately passed out due to the medication error. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse as outlined in OAR 411-020-0002(1)(b)(A)(i). The facility's failure to ensure that AP2 was properly trained to dispense medication, which constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
ALFCP26-00002 $250.00 fine assessed