Violation Details: 00455442-AP-407577

Records Request Print
Date
2/2/2026
Report number
00455442-AP-407577
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
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) is scheduled to receive two medications three times a day, 8:00 am, 2:00 pm and 8:00 pm. On or about February 2, 2026, AV was not given his/her 2:00 pm medication. There was staff confusion about who did or did not give the 2:00 pm medication pass, leading to AV not receiving medication as ordered. The medication that AV missed placed AV at risk for high blood pressure and increased tremors. Respondent failed to ensure staff dispensed medication as ordered, which placed AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
ALFCP26-00108 $188.00 fine assessed