Violation Details: 00425391-AP-376941

Records Request Print
Date
9/7/2025
Report number
00425391-AP-376941
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide inservice
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
411-054-0070(2)(b)
Findings
Alleged Perpetrator #2 (AP2) works at the facility as a caregiver, according to training records. There is no indication that AP2 was trained as a medication technician. On or about September 7, 2025, Alleged Perpetrator #2 (AP2) administered medications to the Alleged Victim (AV), however, AP2 had already administered AV's medications earlier. The medication was administered to AV accidentally, as AV was not sitting in his/her assigned seat, and the resident the medications were intended for looked similar to AV. AV was sent to the hospital and diagnosed with overdose of medication, causing altered mental status, low blood pressure and non-communicative and sleepy. AP2's actions were found to be inconclusive after investigation. Respondent failed to ensure staff were properly trained to carry out resident services for passing medication. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
RCFCP26-00609 $250.00 fine assessed