Violation Details: 00320748-AP-272563

Records Request Print
Date
3/22/2024
Report number
00320748-AP-272563
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: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(a)
Findings
On or about March 22, 2024, when facility staff were conducting a narcotic count, the staff found a discrepancy in Alleged Victim's (AV) Oxycodone count. Based on facility documentation and interviews, AV's narcotic count showed 3mL of AV's Oxycontin was missing. It was unclear what caused the discrepancy in AV's narcotic count. AV suffered no negative side effects as a result of the narcotic error; however, the facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) allegedly financially exploited AV. An investigation determined no abuse occurred by AP2 and AP3.