Violation Details: 00423045-AP-374507

Records Request Print
Date
8/24/2025
Report number
00423045-AP-374507
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to administer medication as ordered
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g)
External site: 411-054-0055(1)(f)
Findings
The Alleged Victim (AV) relies on the facility for care and is care planned to have medication administration done by the facility. On or about August 24, 2025, the Alleged Perpetrator 2 (AP2) gave the AV a nighttime dose of 75 mg of medication for restless leg syndrome instead of the 25 mg that was prescribed for the morning dose. According to documentation, AV experienced increased leg pain following the medication error. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.