Violation Details: 00406363-AP-357376

Records Request Print
Date
6/7/2025
Report number
00406363-AP-357376
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: 411-054-0055(1)(a) and (f)
Findings
On June 7, 2025, Alleged Perpetrator 2 (AP2) neglected Alleged Victim (AV) by failing to notify delegated staff of AV’s return to the facility, resulting in a lack of timely medical care and scheduled medication administration. According to facility documentation and interviews, AV requires regular blood sugar monitoring and scheduled medications as ordered. AV returned to the facility around 4:00 PM after spending three weeks with family and was checked in by AP2. However, AP2 did not inform other staff of AV’s return, which led to AV missing a critical 4:00 PM dose of medication and a pre-dinner blood sugar check. AV’s blood sugar was not assessed until after 7:00 PM, at which point it was found to be abnormally high causing AV unreasonable discomfort. AP2's actions are considered neglect of care which constitutes abuse. The facility failed to ensure a safe and effective medication administration system for AV, which is a violation of Oregon Administrative Rules. Alleged Perpetrator 3 (AP3) allegedly neglected AV. An investigation determined no abuse occurred by AP3.