Date: 9/1/2019
Report Number: 00079388-AP-058721
Allegation: Failed to provide a safe medication administration system
Type: Neglect
Level: 2 - Minor harm or potential for moderate harm
Description: AP1 neglected AV as defined in OAR 411-020-002(1)(b)(a)(i) by failing to take inventory of AV's medications. AV reportedly had Lidocaine patches missing and thus AV was without the pain medication and was left in pain as the Lidocaine patches could not be refilled.
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Result: Substantiated
Findings: On or about early September 2019, it was discovered that some Lidocaine patches for the Alleged Victim (AV) were unaccounted for, leaving AV to have to use pain pills rather than Lidocaine patches for pain. The Alleged Perpetrator #2 (AP2) was found not substantiated in this case. The facility failed to have a safe medication administration system that prevents theft or misuse of medications. The failure is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction: ALFCP21-01290 $250.00 fine assessed