- Date
- 3/20/2020
- Report number
- 00076668-AP-056756
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Findings
- Alleged Victim (AV) requires staff assistance with medication administration and is prescribed short acting insulin to be given before meals and long acting insulin to be given at bedtime. On or about March 20, 2020, Alleged Perpetrator 2 (AP2) administered AV's bedtime insulin. According to the medication administration record AP2 administered 30 units of long acting insulin. Shortly after the administration AV became lethargic and could not stay away. By 10pm AV was non-responsive and staff called emergency services for further medical evaluation. Medics arrived and took AV's blood sugar reading and it was in the range of 36 to somewhere in the 40's. Medics stayed with AV at the facility for approximately an hour, attempting to stabilize AV's blood sugar. AV was transported to the hospital at approximately 11pm. Given the difference in effect of the two types of insulin which AV is prescribed, it is more likely than not that AP2 administered 30 units of AV's short acting insulin at bedtime rather than the long acting insulin in error. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.