Violation Details: 00393804-AP-344486

Records Request Print
Date
4/5/2025
Report number
00393804-AP-344486
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious 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 Perpetrator 2 (AP2) failed to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AP2 failed to administer correct medication to AV, on or about April 5, 2025. As a result of AP2's error, AV experienced adverse reactions to taking the wrong medication which resulted in AV being hospitalized. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules.