Violation Details: 00434884-AP-386743

Records Request Print
Date
10/24/2025
Report number
00434884-AP-386743
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: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on the facility to administer his/her medications. On 10/24/2025, AV was administered Oxycodone 3. 5 hours early and Methadone 5.5 hours early. Alleged Perpetrator 2 (AP2) states AP2 was in the middle of being delegated to administer another medication when AV came up demanding medications. Instead of having AV wait, AP2 admits to pulling the medications out of the medication cart and popping Methadone and Oxycodone into a pill cup. AP2 let AV walk away with the pills. It was not until after AP2 gave AV the pills, AP2 saw the previous shift have given AV the medication. As a result, AV reported feeling ill and having increased pain as the day went on. AP2 failed to provide a safe medication administration system for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which is a violation of Oregon Administrative Rules.