Violation Details: 00474119-AP-426532

Records Request Print
Date
4/17/2026
Report number
00474119-AP-426532
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
On or about April 21, 2026, the facility failed to administer the Alleged Victim’s (AV) prescribed medications as ordered. Based on facility documentation and interviews, when AV moved into the facility on April 17, 2026, staff obtained two medication lists, one of which was outdated. Although staff attempted to confirm the correct orders with AV’s medical provider, updated orders faxed on April 17 were not reviewed by staff until April 21. At time of incident, AV informed staff that some medications being administered were no longer prescribed. On April 21, 2026, AV lost consciousness, resulting in a fall and injury to AV’s leg. Following the fall, AV was confused and unable to recall baseline information. The facility failed to ensure a safe medication administration system for AV, resulting in unreasonable discomfort which constitutes abuse by neglect as outlined in OAR 411 020 0002(1)(b)(A)(i).
Sanction
RCFCP26-00677 $450.00 fine assessed