Print Violation: 00332963-AP-284117

Provider Information

Flagstone Retirement And Assisted Living

3325 COLUMBIA VIEW DR
The Dalles, OR 97058

Date: 5/21/2024
Report number: 00332963-AP-284117
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)(g) and (s)
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 medications. On or about May 21, 2024, at the AM medication pass, AV was given half of his/her pain medication dose. ON or about May 22, 2024, AV was given half of his/her regular pain medication dose, but it was caught by an audit, and AV was given the second (2nd) half of his/her regular pain medication dose. Alleged Perpetrator 2 (AP2) dispensed AV’s pain medication of May 21st and 22nd, 2024, and he/she completed the medication tech training on May 15, 2024. As a result of the medication errors, AV suffered pain and states he/she suffered cramps, felt shaky, nauseous and swats. 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.