Violation Details: 00419794-AP-371150

Records Request Print Provider Details
Date
8/10/2025
Report number
00419794-AP-371150
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on the facility to administer his/her medication. On or about August 10, 2025, AV was administered insulin incorrectly by Alleged Perpetrator 2 (AP2). AP2 received online training and in-person supervision for AP2's position. AP2 was delegated to administer insulin on August 7, 2025. On August 10, 2025, the parameters for administering AV's insulin were not followed by AP2. AP2 failed to provide a safe medication administration system to AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe medication administration system, which is a violation of Oregon Administrative Rules.
Sanction
RCFCP26-00041 $375.00 fine assessed