Violation Details: 00435263-AP-387108

Records Request Print
Date
10/27/2025
Report number
00435263-AP-387108
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) takes pain medication three (3) times a day, for chronic pain. AV’s scheduled pain medication is filled and deliver automatically every two (2) weeks. On or about October 23, 2025, at 12:00 PM, AV missed scheduled doses of pain medication. By using scheduled doses of pain medication to supplement AVs PRN, which resulted in AVs pain medication running out sooner than anticipated, causing AV to miss scheduled doses of AVs pain medication which created risk of serious harm as AV experiences increased pain when AV doesn't get AVs pain medication. Respondent failed to implement meaningful safe medication administration system, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00248 $375.00 fine assessed