- Date
- 5/9/2025
- Report number
- 00400480-AP-351332
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On or about May 9, 2025, the Alleged Victim (AV) was administered medications that were not prescribed to AV, resulting in AV being admitted to the hospital due to a drug overdose. At the time of the incident, Alleged Perpetrator 2 (AP2) was working as the medication technician and was responsible for overseeing medication administration to AV. Based on facility documentation and interviews, it was determined that AP2 failed to provide the basic care and services necessary to maintain AV’s health and safety by instructing Witness 4 (W4) to administer the incorrect medications. As a result, AV experienced a major medical event, requiring admission to the hospital’s critical care unit for three days. Documentation further indicated that five days after the incident, AV remained unsteady, suggesting ongoing effects from the medication error. AP2, in a supervisory role over W4, bears responsibility for directing the improper medication distribution. AP2’s actions constitute serious neglect of care, which meets the definition of abuse. Furthermore, the facility failed to ensure a safe medication administration system for AV which resulted in AV being hospitalized due to drug overdose which a is a violation of Oregon Administrative Rules.