- Date
- 10/20/2025
- Report number
- 00437884-AP-389741
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- According to the documentation, the Alleged perpetrator 2 (AP2) failed to follow the care plan to notify the RN and medical professional when the Alleged Victim’s blood sugar was low. Directions on the MAR stated any blood sugar less than 80 the RN and the PCP needs to be notified. The AP2 did not notify the low blood sugar to the RN or the PCP. On or about October 20, 2025, the AV’s blood sugar was approximately 66. The AP2 gave the AV orange juice and breakfast and came back a little while later to re-check their blood sugar. At this time, the blood sugar was 55. AP2 gave more orange juice to the AV and checked on the AV and they were unresponsive. The AV later passed away due to complications from this incident, which is a violation of resident rights, is considered neglect of care and constitutes abuse. the facility failed to follow the care plan, which is a violation of Oregon Administrative Rules.