Print Violation: 00159894-AP-126866

Provider Information

Bonaventure of Keizer Assisted Living

5525 MCLEOD LANE NE
Keizer, OR 97303

Date: 9/12/2021
Report number: 00159894-AP-126866
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: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) relies on the facility to administer his/her medication. On or about September 12, 2021, Alleged Perpetrator 2 (AP2), went to administer AV’s daily dose of insulin. AP2 thought that AP2 had prepped the pen with 40 units of slow acting insulin but had prepped the fast-acting insulin. AV said, “that’s a lot don’t you think?”, AP2’ re-read the medication and realized the mistake he/she had made. AV was hospitalized due to the medication error. AP2’s failed to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which is a violation of Oregon Administrative Rules.