Violation Details: 00417015-AP-368379

Records Request Print
Date
4/19/2025
Report number
00417015-AP-368379
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
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(1)(a) and (b)
External site: 411-054-0030(f)
External site: 411-054-0036(2)(b), (c), and (g)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on AP1 to ensure their personal care, safety, and needs are met. AV service plan indicates AV relies on AP1 for all medication management. AP1 staff are to issue a reorder of medications. AV did not receive the scheduled neurological medication due to the facility not having the medication on site from April 19, 2025. to April 25, 2025, for a total of four missed doses. At the time of the incident, there was no established policy or procedure in place to address missed medication administrations. Additionally, no investigation was conducted to determine whether the missed doses resulted in actual harm or posed a risk of harm to AV. Respondent failed to provide a safe medication system, and failed to administer AV's medications as prescribed. This constitutes abuse by neglect as defined by OAR's.
Sanction
RCFCP25-01323 $500.00 fine assessed