Print Violation: 00223785-AP-182389

Provider Information

Fieldstone Village at Keizer Ridge

1165 MCGEE COURT NE
Keizer, OR 97303

Date: 9/28/2022
Report number: 00223785-AP-182389
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious 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)(r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: On or about September 27, 2022, Alleged Perpetrator #2 (AP2) gave old seizure medication to the Alleged Victim (AV). This medication had been discontinued by AV's physician due to the medication not working and AV receiving new seizure medication. AV knew it was the incorrect medication, AV did not take it and AP2 did not stay to witness AV taking the medication. AV's correct medication was in the overstock area, AP2 grabbed the incorrect medication. AV suffered a seizure the next morning. AP2 had made prior medication errors at the facility, however, the facility failed to provide additional training to ensure prevention of future medication errors. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP22-00926 $1125.00 fine assessed