Date: 5/12/2020
Report Number: 00097867-AP-074135
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 411-020-0002(1)(b)(A)(ii) by the active or passive failure to provide the basic care or services necessary to maintain the health and safety of AV, resulting in AV stockpiling many Oxycodone, creating the risk of harm if taken improperly.
Rule(s) Violated: 411-054-0028(2)
411-054-0055(1)(a)
Result: Substantiated
Findings: On or about April 2, 2020, staff found a liquid measure med cup in a drawer with approximately fifteen (15) Oxycodone. The facility kept conflicting records of when AV's medication administration order changed to being administered by staff only. On or about May 12, 2020, approximately thirty (30) oxycodone were found in a drawer in AV's room. Staff did not take the medications out of AV's room but took a picture to notify management. Later the same day staff went to retrieve the medications and the medications were missing. It is unknown what happened to the medications. The facility failed to provide a safe medication administration system which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: ALFCP21-01184 $338.00 fine assessed