- Date
- 2/22/2024
- Report number
- 00314791-AP-267102
- 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) resides in a secure facility that has a responsibility to provide care and a safe environment. AV is prescribed multiple scheduled and as needed medications and a trained med tech is responsible for ordering, storing, and administering all of AV's medications per physician orders. On or about February 21, 2024, a medication cart audit was completed, and narcotic discrepancies was found. These discrepancies involved inaccurate counts as well as missing/tampered with bottles of morphine. AV's morphine was determined to be watered down. AP1 failed to ensure a safe, adequate medication administration system, which resulted in AV's prescribed morphine being diverted by an unknown Alleged Perpetrator (AP2). AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failure is a violation or Oregon Administrative rules.