Violation Details: 00433352-AP-385273

Records Request Print
Date
10/17/2025
Report number
00433352-AP-385273
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), 411-054-0027(1)(g) and (s), 411-054-0028(2), and 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility to administer medications as ordered by their physician. On October 17, 2025, AP2 was being shadowed by another staff member and told not to administer medications unless being observed by the staff member, but AP2 administered the medication to AV and gave AV another resident's medication. AV was sent to the hospital due to being administered the wrong medication by AP2. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. AP2 failed to provide a safe medication administration system for AV, which is considered neglect and constitutes abuse.