Date: 5/19/2016
Report Number: ES165887
Allegation: Failed to provide a safe medication administration system
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Description: RV reported running out of pain medication, deciding to try and detox about one day and then began taking the pills again. RV reported on 5/15/2016 RV received a pill at 1:00 A.M. and then prn medication at 5:00 A.M. and RV's blood pressure was 189/149. RV reported staff are not appropriately documenting the time RV received medication. Witnesses report and documenting reviewed indicate RV refusing medication when RV first arrived. W5 reported RV did run out of a specific medication at one time as the pharmacy failed to deliver as they had said they would. RV's physician was notified and RV had another medication ordered, but RV refused to take this medication after one dose. Record review did not support RV's alleged blood pressure reading. RV's blood pressure was 173/83 and half an hour later it was 146/88. Oregon Administrative Rue violation occurred.
Rule(s) Violated: 411-086-0200(3)(b)
Result: Substantiated
Findings: The facility failed to maintain an adequate medication system.