Violation Details: 00383286-AP-333784

Records Request Print
Date
2/8/2025
Report number
00383286-AP-333784
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: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) is a resident of the facility who requires total assistance with his/her medications. On or about February 12, 2025, it was discovered that Alleged Perpetrator 2 (AP2) failed to administer AV's prescribed medication as ordered between February 8 and February 10, 2025. Based on facility documentation and staff interviews, AP2 did not follow AV's prescribed medication schedule. As a direct result of this failure, AV experienced increased swelling and pain in both feet, causing unreasonable discomfort and pain. AP2’s failure to carry out AV's medication orders as prescribed is considered neglect of care and constitutes abuse. The facility failed to ensure adequate professional oversight of the medication administration system for AV, which is considered a violation of Oregon Administrative Rules.