Violation Details: 00402346-AP-353255

Records Request Print
Date
5/16/2025
Report number
00402346-AP-353255
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: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) receives his/her medication from facility staff. On or about May 9, 2025, Alleged Perpetrator #2 (AP2) administered the incorrect insulin to AV, as the incorrect medication was obtained by AP2 from another pharmacy, and AP2 did not check to ensure the medication was the correct type for AV, which placed AV at risk for serious harm. On or about May 13 to May 15, 2025, AV missed three doses of insulin, due to orders not being placed in the system correctly. Alleged Perpetrator #3 (AP3) edited the original order for AV's insulin to 7:40 am, 8:00 am and 4:00 pm, resulting in AV's blood sugars not being checked or receiving his/her medication at lunch time for three days, causing AV to be hospitalized due to an adverse reaction and uncontrolled blood sugar levels. AP2 and AP3's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure a safe medication administration system is a violation of Oregon Administrative Rules.