Violation Details: 00453976-AP-406098

Records Request Print
Date
1/9/2026
Report number
00453976-AP-406098
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
411-054-0025(1)(a) and (b)
411-054-0027(1)(g)
411-054-0055(1)(a) and (f)
Findings
On January 9, 2026, Alleged Perpetrator 2 (AP2) made a medication administration error involving the Alleged Victim’s (AV) prescribed narcotic pain medication. Facility documentation and interviews show that AP2 administered 2.5 mg instead of the prescribed 5 mg after inadvertently selecting medication from the incorrect bubble pack. As a result of receiving the incorrect dosage, AV complained of pain and experienced disturbed sleep due to breakthrough discomfort. During the interview, AP2 stated that the error occurred because he/she was fatigued after working a 15-hour shift on the day of the incident and was distracted while simultaneously investigating another facility matter. AP2 did not report any concerns related to training, competency, or unfamiliarity with the medication that contributed to the error. The facility was short-staffed that day due to another employee calling out, and AP2 had volunteered to stay and assist with medication administration. AP2’s failure to administer the correct dosage of AV’s prescribed narcotic pain medication resulted in unreasonable discomfort to AV. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration for AV which is a violation of Oregon Administrative Rules.