Violation Details: 00328920-AP-280243

Records Request Print
Date
5/3/2024
Report number
00328920-AP-280243
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: 411-054-0027(1)(s)
External site: 411-054-0055(1)(a) and (f)
Findings
On May 2, 2024, facility discovered that one of Alleged Victim's (AV) card of 28 narcotics was missing from the medication cart. Based on facility documentation and interviews, several narcotic medications counting errors were found on the facility's NARC log between staff hand-offs including no double signatures, missing signatures, and missing times. It was reported that medications are to be counted and logged together during the shift change and hand-off the medication cart. It was determined to be unclear if there was an initial counting error or if a full sheet of AV's narcotics went missing. AV did not experience any negative outcome from this incident and AV did not experience any discomfort or pain due to the missing medications. Although, there was no negative outcome to AV, the facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. An unknown Alleged Perpetrator 2 (AP2) financially exploited AV. An investigation determined no abuse occurred.