Violation Details: 00396000-AP-362541

Date
4/17/2025
Report number
00396000-AP-362541
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to administer medication as ordered
Result
Substantiated
Findings
The Alleged Victim (AV) relies on the facility for care and is care planned to have medication administration done by the facility. The AVs Medication Administration Record (MAR) contains an order for a medication patch to be placed on AV every morning and prior to administration to have the old patch removed. According to an investigation, on or about April 17, 2025, the Alleged Perpetrator 2 (AP2) administered AV's medication patch and did not remove the patch that was already in place. AV was found later in the day with two patches on their body, which placed AV at risk for harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.
Sanction
RCFCP25-01028 $1500.00 fine assessed