- Date
- 9/18/2025
- Report number
- 00428547-AP-380256
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff to meet AV’s daily care needs. AV’s service plan indicates that facility staff are responsible for administering AV’s medications in accordance with the physician’s orders. AV is prescribed a medication patch, and the physician’s order specifies that the previously applied patch must be removed prior to applying a new one.
On or about September 19, 2025, Witness 2 (W2) was administering AV’s medication patch and discovered that AV had two patches already in place. Alleged Perpetrator 2 (AP2) had not removed the prior patch before applying a new one. As a result, AV had two previously applied patches remaining on their skin. AP2’s actions constitute neglect of care and meet the definition of abuse. Additionally, the facility failed to maintain a safe medication administration system, which is a violation of Oregon Administrative Rules.
- Sanction
- RCFCP26-00411 $500.00 fine assessed