Print Violation: 00072170-AP-052743

Provider Information

The Arbor at Avamere Court

450 CLAGGETT COURT N
Keizer, OR 97303

Date: 2/19/2019
Report number: 00072170-AP-052743
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: 411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) is on a bowel regiment which includes scheduled and as needed medications for constipation/diarrhea. There are orders for the facility to administer Milk of Magnesia after no bowel movement for two days/48 hours, and then a stool softener can be given four (4) hours after this if not effective. On or about February 18, 2019, bowel charting shows that AV had a bowel movement at the end of the day. On February 19, 2019, AV was administered Milk of Magnesia and the stool softener in error. There were no documented side effects from the outcome of the bowel medications. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.