- Date
- 7/18/2025
- Report number
- 00414723-AP-365965
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a safe medication system by not reorder medications for the Alleged Victim (AV). The AV’s medication needs to be reordered by the med tech on the 3rd of every month. The medication was not reordered, and the AV did not receive their potassium medication on or about July 16, 2025, at the scheduled 8 am time. At around 10 am that morning, the AV was admitted to the hospital for low potassium and remained in the hospital for approximately 5 days before returning to the hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.