Violation Details: 00387610-AP-338102

Records Request Print
Date
3/7/2025
Report number
00387610-AP-338102
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: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) is scheduled to receive insulin from the facility. AV receives long and fast acting insulin. On or about March 7, 2025, Alleged Perpetrator #2 (AP2) was dispensing medication and gave AV the wrong insulin. AV's blood sugar decreased to 40, where AV felt shaky and had to be given glucose in order to counter effect the medication given. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.