- Date
- 8/26/2025
- Report number
- 00422483-AP-373949
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On August 26, 2025, ODHS Adult Protective Services (APS) initiated investigation #00422483 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility. The APS investigation determined that on or about August 22, 2025, the facility failed to provide a safe medication administration system to ensure AV’s medications were administered as ordered. Facility documentation, staff interviews, and APS Investigator observations confirm that the facility did not provide adequate oversight of medication administration by Alleged Perpetrator 2 (AP2), Alleged Perpetrator 3 (AP3), and Alleged Perpetrator 4 (AP4), which resulted in multiple medication errors and caused AV unreasonable discomfort, including increased pain, heightened anxiety, and sleep difficulties. The facility's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse. AP2 had a professional duty to administer medications to AV as ordered. On August 22, 2025, AP2 provided an incorrect opioid dosage to AV, which resulted in unreasonable discomfort to AV in the form of increased pain. AP2's actions is considered neglect of care which constitutes abuse. AP3 had a professional duty to administer medications to AV as ordered. On August 22, 2025, AP3 provided an incorrect opioid dosage to AV, which resulted in unreasonable discomfort to AV in the form of increased pain. AP3's actions is considered neglect of care which constitutes abuse. AP4 had a professional duty to administer medications to AV as ordered. On August 22, 2025, AP4 failed to administer medications to AV as ordered by giving the incorrect dose of opioid to AV, which resulted in unreasonable discomfort to AV in the form of increased pain. AP4's actions is considered neglect of care which constitutes abuse.
- Sanction
- ALFCP26-00024 $500.00 fine assessed