Violation Details: 00460411-AP-412693

Records Request Print
Date
2/25/2026
Report number
00460411-AP-412693
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)
411-054-0055(1)(a) and (f)
Findings
On or about February 25, 2026, at approximately 8:30 PM, Alleged Perpetrator 2 (AP2) administered Alleged Victim's (AV) medication twice instead of once, resulting in AV receiving an extra dose. Based on facility documentation and interviews, AP2 had been trained and deemed competent to administer medications, including the requirement to perform a triple-check prior to each administration. As a result of AP2's medication administration of AV's medication, resulted in AV experiencing unreasonable discomfort which included confusion, drowsiness, and lethargy. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules.