Violation Details: 00395497-AP-346199

Records Request Print
Date
4/3/2025
Report number
00395497-AP-346199
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: 411-054-0030(1)(f)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about April 3, 2025, Alleged Victim (AV) did not receive his/her insulin as ordered. Based on facility documentation and interviews, Alleged Perpetrator 2 (AP2) failed to administer AV's 4:30PM scheduled dose of insulin. As a result, AP2 was investigated for neglect. An investigation determined AV did not experience a negative outcome from missing this dose and determined no abuse occurred by AP2. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.
Sanction
RCFCP25-00728 $500.00 fine assessed