Print Violation: 00235526-AP-192983

Provider Information

Dorian Place Assisted Living Facility

375 N DORIAN DR
Ontario, OR 97914

Date: 12/3/2022
Report number: 00235526-AP-192983
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 (r)
Findings: Alleged Victim (AV) relies on the facility to administer his/her medication. On or about December 3, 2022, AV went to the med cart and requested his/her PRN medication for nausea. Alleged Perpetrator 2 (AP2) made an error by administering a medication for antipsychotic/antiemetic that was not prescribed to AV. AP2 stated that the med error was his/her fault; AP2 deviated from protocol and did not check AV’s MAR for available PRN medications first. As a result of the medication error, AV complained of a headache. AP2 failed to provide a safe medication administration system for AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe medication administration system, which is a violation of Oregon Administrative Rules.