- Date
- 4/29/2025
- Report number
- CALMS - 00080702
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Based on interview and record review conducted during a site visit on 05/07/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). The facility failed to provide ordered treatments for 11 out of 18 days after which the resident was hospitalized with sepsis (life-threatening bodily response to an infection). Findings include, but are not limited to:
During a Compliance Specialist's (CS) onsite visit on 05/07/25, Resident 1 was out of the facility at the local hospital. The CS was unable to interview Resident 1 or make observations during the site visit.
A review of physician’s orders indicated the following:
- On 03/27/25, soak the toe in warm water with very diluted Epsom salt for 10 minutes twice daily for one week, then switch to once-a-day soaks until drainage stops. Massage the toe after soaks to help decrease scab formation. Apply betadine ointment to the area and cover with a loose band-aid;
- On 04/16/25, soak the right food in an Epsom salt bath, apply betadine ointment, and band-aid once daily; and
- On 04/25/25, discontinue betadine soaks, change dressing every 48-72 hours, and saline to remove dressing when needed.
Staff 1 stated on 04/01/25, the facility transferred systems for tracking treatments and medication orders to Point Click Care (PCC). As a result of the system change, the doctor’s orders from 03/27/25 had not been transferred to the April Treatment Administration Records. Staff 1 stated the doctor’s orders dated 04/25/25 had not been entered into the TARs and had not been implemented by staff. A review of the TARs for 03/01/25 through 03/31/25 indicated Resident 1 had not received treatment for wound care on 03/24/25. The TARs for 04/01/25 through 04/30/25 indicated that the treatment to soak Resident 1’s toe was to be completed twice daily. The treatment was not completed for 11 out of 18 occurrences between 04/11/25 until hospitalization on 4/29/25. Staff 4 and Staff 8 stated Staff 9 marked the TARs as having completed treatment for soaking Resident 1’s toe on 04/26/25, however, Staff 4 and Staff 8 indicated Staff 9 had not completed the treatment and had not known how to fix the documented error in the system. On 04/29/25 at 11:58 am, the LPN noted, after speaking with the med tech, it had come to our attention that the treatment was not done, and s/he had not known how to correct the incorrect documentation. S/he ran out of time and was unable to do the treatment on 04/26/25. Corrective Action was taken on this allegation.
The facility's failure to carry out medication and treatment orders as prescribed was substantiated. The facility failed to monitor that treatments were provided as ordered. The toenail area worsened, and Resident 1 was hospitalized with sepsis which is considered a violation of Oregon Administrative Rules.