Violation Details: 00407142-AP-358207

Records Request Print
Date
6/11/2025
Report number
00407142-AP-358207
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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) suffered a fractured ankle on June 7, 2025, which was causing AV increased pain. On or about June 9, 2025, due to increased pain, hospice increased AV's pain medication. Staff thought that hospice canceled AV's current medication and did not have the new order for AV's pain medication. When staff checked for the new order, later it was discovered that the fax machine had been unplugged, therefore, hospices new order could not get through. Hospice did not cancel the current order and staff could have given AV pain medication through the old medication order. AV went without pain medication for at least 5 hours, leaving AV in pain and unreasonable discomfort. Respondent failed to provide a safe medication administration system. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
RCFCP26-00171 $1500.00 fine assessed