Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: OR0001081700
Provider Information
The Amber Senior Living
365 SW BEL AIR DRIVE
Clatskanie, OR 97016
- Provider ID
- 70A287
- Administrator
- Gelissa Crichton
- Phone
- (503) 728-2744
- gcrichton@sapphirehealthservices.com
Violation Details
- Date
- 3/23/2016
- Report number
- OR0001081700
- Type
- Licensing Violation
- Level
- 1 - No harm or potential for minor harm
- Allegation
- Falsified records
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0025(8)(a)
- Findings
- Substitue one resident's narcotics for another resident's narcotics4110540025(8)(a)On April 1, 2016, Compliance Specialist (CS) interviewed Staff 2 to determine if the facility has a policy that prohibits falsification of records. Staff 2 indicated his/her staff will not compromise safety of residents, all staff know medication cannot be substituted when facility is running short on medications for a particular resident.On April 1, 2016, CS interviewed Resident 1 who indicated he/she takes narcotics for pain. Resident 1 also indicated he/she has never been informed the facility has run out of his/her narcotics before.On April 1, 2016, CS interviewed Resident 2 who indicated he/she receives their medication (narcotics for pain) regularly and has not been informed recently of the facility running out of his/her medication.On April 1, 2016, CS interviewed Resident 3 who indicated he/she takes narcotics for pain. Resident 1 also indicated he/she has never been informed the facility has run out of his/her narcotics before.On April 7, 2016, CS received Medical Administration Records (MARs) for 3 Sample Residents (Residents 1, 2 & 3) to determine if documentation were appropriate. Notations in Resident 2 ' s December 2015 MAR appeared inconsistent because Resident 2 ' s MAR did not match his/her pill count in the facility ' s Narcotic Log; there were inaccurate pill counts for 7 dates (3rd, 5th, 14th, 17th, 21st, 25th & 27th) in December. Resident 2 ' s January 2016 MAR also appear inconsistent because Resident 2 ' s MAR did not match his/her pill count in the facility ' s Narcotic Log; were inaccurate pill counts for 4 dates (4th, 11th, 30th & 31st) in January.On April 19, 2016, CS was contacted by Staff 4 via phone. Staff 4 indicated Staff 1 worked the floor the night before and applied another resident ' s pain cream to Resident 4 when Resident 4 was complaining of pain. Resident 4 had an adverse reaction to the topical medication and had to be admitted into the hospital later that night. On April 20, 2016, CS was contacted again via phone by Staff 4 who stated medical staff located an empty box for pain topical cream in the Medical Room trash can that morning. It was a box for Resident 5 ' s pain medication. Staff 4 took a picture of the box of medication and emailed it to CS for review. CS asked Staff 4 if they ' ve located the missing medication and Staff 4 indicated Resident 4 took the medication that was applied to his/her back with him/her to the hospital. On April 26, 2016, CS reentered the facility and interviewed Staff 1 about incident involving Resident 4. Staff 1 indicated he/she applied a topical pain reliever to Resident 4 ' s back. Staff 1 indicated he/she also had a topical pain relieving creamResident 5 ' s topical pain medication) in his/her possession when he/she applied a topical pain relieving cream prescribed for R4 Staff 1 also said he/she mistakenly left Resident 5 ' s topical pain medication on counter in Resident 4 ' s room.On April 26, 2016, CS interviewed Staff 3 about the incident involving Resident 4. Staff 3 stated he/she was informed by Staff 6 that Staff 1 put topical pain medication on Resident 4 and soon after Resident 4 ' s pulse accelerated and Resident 4 started feeling badly. Staff 3 further indicated Resident 4 has a doctor ' s order on file for a topical pain relieving cream but was told by staff that Staff 1 used Resident 5 ' s topical pain relieving cream instead. Staff 3 confirmed staff believes Resident 4 has Resident 5 ' s topical pain relieving cream in his/her possession.On April 26, 2016, CS secured a copy of Resident 5 ' s April 2016 MAR that showed an order for a different topical pain relieving cream than resident 4s . CS went to the Medical Room where Staff 4 was on duty and asked to see where Resident 5 ' s medication is kept. Staff 4 showed where current medication for Resident 5 is kept and also showed where medication Resident 5 is no longer using is kept. There was one unused/unopened box of topical pain relieving cream in that drawer. Staff 4 indicated prior to the incident involving Resident 4, there were two unused/unopened boxes of topical pain relieving cream in that drawer.On April 26, 2016, CS interviewed Staff 5 who indicated he/she was working on April 19, 2016 when Resident 4 had to go to the hospital. Staff 5 was told by Resident 4 he/she was not feeling well and had back pain. Staff 5 indicated he/she was told by Resident 4 that Staff 1 applied a topical cream that increased (not relieved) his/her back pain.On April 26, 2016, CS visited Resident 4 in a rehabilitation center. Resident 4 indicated Staff 1 applied a cream to his/her back on April 20th and he/she had a bad reaction to it. Resident 4 indicated it was not his/her topical pain medication and handed CS a tube of topical pain relieving cream. Resident 4 indicated Staff 1 used this topical pain relieving cream on him/her and left it behind.