Print Violation: 00060087-AP-042825

Provider Information

Pelican Pointe Assisted Living Community

615 WASHBURN WAY
Klamath Falls, OR 97603

Date: 12/1/2019
Report number: 00060087-AP-042825
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)(f) and (r)
External site: 411-054-0028(2)
External site: 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) medication orders were followed for administration of insulin. On or about December 1, 2019, AV was given his/her insulin by two different med aides, one of which was not delegated to give insulin, resulting in an overdose of medication, placing AV at a risk of serious harm. The AV was transported to the hospital and admitted overnight. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP20-00341 $225.00 fine assessed