- Date
- 6/21/2025
- Report number
- 00409379-AP-360437
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to administer ordered medication
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility to administer his/her medications. AV is able to verbalize when AV is experiencing pain. AV does so with frowning, facial grimacing, pulling away when touched, unusual behaviors, refusal of care or medications, or guarding an area of AV's body. The medication that Alleged Perpetrator 2 (AP2) had missed administering to AV had direction to be administered at two tablets by mouth 3 times daily for pain. The times listed to be administered were 9:00 am, 2:00 pm, and 8:00 pm. On or about June 21, 2025, the 2:00 pm time for the medication was filled out by Witness 1 (W1) and then circled. June 21, 2025, at approximately 4:30 pm, staff discovered that AV did not receive AV's 2:00 pm medication. Staff discovered that staff members from the shift prior “did not sign or pop" AV’s 2:00 pm medication. AV experienced pain due to missing the 2:00 pm medication. AP2 had failed to administer a medication to AV, which is neglect of care and constitutes abuse. The facility failed to assure AV’s medication was administer, which is a violation of Oregon Administrative Rules.