- Date
- 10/28/2025
- Report number
- 00435306-AP-387177
- 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) relies on the facility for his/her care needs. Witness 1 (W1) self- reported that Alleged Perpetrator 2 (AP2) had approached W1 and explained that AP2 gave the AV a short acting metabolic blood disorder medication when it was supposed to be a long acting/ slow-release metabolic blood disorder medication. W1 stated that AP2 told W1 that it was accidental and that AP2 became “distracted” while conversing with another staff member. W1 stated that due to the medication that was given, it could have put the AV’s levels in a dangerous position and the AV “could have” died as a result. AP2 failed to provide a safe medication administration system for AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe medication administration system, which is a violation of Oregon Administrative Rules.