- Date
- 9/10/2025
- Report number
- 00426318-AP-377983
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- On September 10, 2025, it was reported that Alleged Victim (AV) did not receive his/her routinely scheduled agitation medication as prescribed, and AV did not receive his/her as needed dose of agitation medication when requested. At time of incident, Alleged Perpetrator 2 (AP2) was working his/her first shift at the facility and AP2 was responsible to administer AV's medication as ordered. Following a review of facility documentation and staff interviews, it was determined that AV did receive their routine agitation medication; however, the dose was not documented in AV's Medication Administration Record (MAR). This failure was due to AP2 not being properly trained on the facility’s medication administration system. AV did not experience a negative outcome at time of incident; however, the facility failed to ensure adequate training and proper oversight of AV's medication administration which is a violation of Oregon Administrative Rules. AP2 allegedly neglected AV. An investigation determined no abuse occurred by AP2.