Violation Details: 00398442-AP-349126

Records Request Print
Date
4/3/2025
Report number
00398442-AP-349126
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) receives his/her medication from the facility. On or about April 30, 2025, AV was placed on alert for being given his/her insulin incorrectly. AV was to have his/her blood sugar levels checked to determine which, if any, insulin to give AV. On multiple occasions, AV was given the incorrect insulin, or no insulin at all, placing AV at risk for harm. The Respondents failure to provide a safe medication administration system placed AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00034 $188.00 fine assessed