Violation Details: 00305119-AP-258062

Records Request Print
Date
1/3/2024
Report number
00305119-AP-258062
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide a safe medication administration system
Result
Substantiated
Rule(s) Violated
External site: 411-054-0055(1)(a) and (f)
Findings
On or about January 2, 2024, Witness 4 (W4) was starting his/her shift and while W4 counted the facility's supply of narcotic pain medication. W4 observed multiple cards of narcotic pain medication had been tampered with. A total of 14 pills of AV's narcotic pain medication appeared to have been diverted. The narcotic pain medication had been removed and replaced with other, unknown medication from an unknown source. Based on documentation, AV did not miss any medications and AV was not administered any medication that was contained in the tampered-with medication cards. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly financially exploited AV. An investigation determined no abuse occurred by AP2. Alleged Perpetrator 4 (AP4) allegedly financially exploited AV. An investigation inconclusively determined no abuse occurred by AP4.