Violation Details: 00430112-AP-381904

Records Request Print
Date
9/26/2025
Report number
00430112-AP-381904
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about September 26, 2025, the Alleged Victim’s (AV) blood pressure medication was ordered by AV's physician to be increased from 5 mg to 10 mg. The facility did not accurately process and implement this physician’s order. As a result, AV did not receive the increased dosage until September 30, 2025, four days after the order was issued. During this period, AV experienced elevated blood pressure readings but did not report pain or suffer adverse side effects. Although AV did not experience a negative health outcome, the facility failed to administer AV's medication as prescribed which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.