Violation Details: 00312722-AP-265178

Records Request Print
Date
2/11/2024
Report number
00312722-AP-265178
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: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on the facility to administer his/her medications. On or about February 11, 2024, one of AV’s narcotic pills was unaccounted for at the end of swing shift, Alleged Perpetrator 2’s (AP2’s) shift. At the start of the shift and last narcotics count, all pills were accounted for. AP2 was the only person in the building with a medication cart key. AP2 failed to provide a safe medication administration system, which is a neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which is a violation of Oregon Administrative Rules.