Violation Details: 00444443-AP-396429

Records Request Print
Date
11/18/2025
Report number
00444443-AP-396429
Type
Abuse: Neglect
Level
4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation
Failed to administer medication as ordered
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility for their care, including medication administration with an order for anticoagulation medication once a day. According to an investigation, due to a medication entry error, AV received anticoagulation medication twice a day from approximately November 18, 2025, to December 8, 2025, resulting in pain, bruising, and a GI bleed. AV was sent to the hospital and was given three units of blood. The facility failed to administer medication as ordered and appropriately train the facility staff member responsible for the error, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i). The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be Not Substantiated.
Sanction
ALFCP26-00257 $1500.00 fine assessed