- Date
- 5/27/2025
- Report number
- CALMS - 00089174
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Based on observation, interview and record review, conducted during a site visit on 09/12/25, the facility's failure to have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications administered by the facility was substantiated for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5). Findings include, but are not limited to: A review of the facility’s policies for narcotic count and discarding medications indicated the following:
· Disposal of outdated, discontinued, or left behind drugs will occur no longer than 3 to 5 days after medications labeled as such;
· After death, medication will be disposed of within 24 hours; and
· Discarded narcotics must be viewed by two of the following staff members: the RN, Director of Health Services, the Administrator, the Executive Director, and the Med Tech.
A review of the narcotic logs for Residents 1, 2, 3, 4, and 5 indicated the following:
· Resident 1’s Morphine Sulfate disposition date 05/24/25 with two staff signatures, one of which was Staff 2's (Wellness Director);
· Resident 2’s Morphine Sulfate disposition date 05/20/25 with two staff signatures, one of which was Staff 2's;
· Resident 3’s Morphine Sulfate disposition date 05/25/25, signed by Staff 2;
· Resident 4’s Morphine Sulfate disposition date 05/25/25, signed by Staff 2; and
· Resident 5’s Morphine Sulfate disposition date 06/10/25, signed by Staff 2.
Residents 2, 3, and 4 had passed away. Compliance Specialist observed on 09/12/25 the above medications had not been destroyed.
In an interview, Staff 2 stated:
Resident's 1 and 5 morphine were to be destroyed because the facility had concerns an employee had diluted the narcotic;
S/He had documented the destruction of the narcotics, but had not destroyed them on the dates indicated on the disposition logs because it was "before a holiday weekend;" and
S/He thought s/he would need to show the narcotics to Adult Protective Services. Department records indicated Adult Protective Services had photographed the resident's medication on 06/10/25.
The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.