Violation Details: 00153913-AP-121928

Records Request Print
Date
6/28/2021
Report number
00153913-AP-121928
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Allegation
Failure to provide a system that prevents theft or misuse of medication
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
On or about June 28, 2021, it was discovered that the morphine for the Alleged Victim (AV) had been diluted. Staff noticed it changed from a hot pink color to a pale pink color. Also, AV had been complaining that his/her pain had not been alleviated by the normal dose of pain medication. On or about June 29, 2021, all Medication Technicians at the facility were drug tested, and all were negative except Alleged Perpetrator #2 (AP2). AP2's actions caused unreasonable discomfort for AV. AP2 is responsible for theft of medication, which is a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility failed to ensure AV's medication was safe, which is a violation of Oregon Administrative Rules.