Violation Details: 00210123-AP-169819

Date
7/6/2022
Report number
00210123-AP-169819
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Findings
Alleged Victim (AV) relies on the facility for his/her care. On or about July 6, 2022, it was discovered that AV was missing narcotic medication from the facility medication cart. During the investigation it was discovered that the Alleged Perpetrator 2 (AP)2) was observed on video removing the medication cart from the medication room, out of the view of facility cameras, as well as returning to the medication room and placing items in his/her bag/backpack. AP2 signed out at least 7 doses of narcotics that were not administered to AV. AP2’s actions are considered theft and financial exploitation and constitute abuse. The investigation into the facility's responsibility of neglect of care resulting in abuse was inconclusive. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.