Print Violation: 00313731-AP-266233

Provider Information

Laurelhurst Senior Living

3120 SE STARK
Portland, OR 97214

Date: 2/16/2024
Report number: 00313731-AP-266233
Type: Licensing Violation
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)
Findings: On or about February 16, 2024, Alleged Perpetrator 2 (AP2) administered another resident's medication to Alleged Victim (AV) in error. Based on facility documentation and interviews, AP2 did not follow the protocol for placing medication cups into resident-specific dividers on the medication cart and did not verify if the medication cup was for the correct resident before administering it to AV. As a result of AP2's error, AV became ill, appeared pale, and complained of dry heaves. AV was sent out to the hospital and was diagnosed with accidental medicine ingestion. AV experienced sedation and dizziness due to the accidental medication ingestion. AP2's actions caused AV unreasonable discomfort which is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules.