- Date
- 4/6/2024
- Report number
- 00323799-AP-275371
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to protect resident from financial exploitation
- Result
- Substantiated
- Findings
- Alleged Victim's (AV's) Services Plan indicates staff will order, store, and administer medication per doctor's orders. On or about April 6, 2024 during Alleged Perpetrator's #2 (AP2's) shift AP2's medication carts were audited, and AV's (PRN) Morphine Solution was diluted with an unknown substance. AV had not been administered AV's Morphine for two months. Prior to the incident, Narcotics had gone missing from the facility, which prompted an audit of AP2's medication carts. AV's Narcotic Log shows that AP2 didn't sign the medication out on April 6, 2024. The staff's inconsistent counting of liquid medications creates a conflict with the accurate tally of the medication, suggesting the possibility that it could have been tampered with before AP2's shift on April 6, 2024. The facility provided training to AP2 about Resident's Rights having the right to be free from neglect and financial exploitation. An Unknown Alleged Perpetrator #3 (AP3) is responsible for financial exploitation. The facility failed to provide a safe medication and protect AV from financial exploitation administration system which is a violation of Oregon Administrative Rules.