Violation Details: 00409079-AP-360267

Records Request Print
Date
6/19/2025
Report number
00409079-AP-360267
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)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relied on the facility for care, medication administration, and medication management. On or about June 19, 2025, the Alleged Perpetrator 2 (AP2), handed AV medications belonging to another resident in error. AV was monitored and was sent to the hospital when they became shaky and were sweating excessively. According to an investigation, it was discovered there were not clear expectations and training on how to properly prepare and administer medications to multiple residents. The allegation against AP2 was unsubstantiated. The facility failed to provide a safe medication administration system, which is a violation of resident rights is considered neglect of care and constitutes abuse as defined by Oregon Administrative Rule 411-020-0002(1)(b)(A)(ii).
Sanction
ALFCP26-00256 $375.00 fine assessed