- Date
- 6/6/2019
- Report number
- 00034611-AP-024368
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Perpetrator 2 (AP2) failed to administer Alleged Victim's (AV) insulin as ordered by AV's physician due to AP2 recording AV's blood sugar levels incorrectly. AP2's error caused AV to become weak resulting in AV suffering a fall with injury. AP2's actions are considered neglect of care and constitutes abuse. The facility is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.