- Date
- 1/25/2025
- Report number
- CALMS - 00083909
- 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 interview and record review, conducted during a site visit on 03/18/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Findings
include, but are not limited to:
- A medication error report for Resident 1, dated 01/29/25, indicated the facility had been notified by Resident 1’s physician of an issue with his/her medication beginning on 01/22/25.
- Staff 3 stated Resident 1’s Torsemide 20mg (diuretic) had been prescribed to be administered for 14 days beginning on 01/21/25, and the med tech had entered the order into the facility’s system to be administered
every 14 days.
- Resident 1’s MAR, dated 01/01/25 through 01/31/25, indicated his/her Torsemide 20mg had been entered multiple times into the MAR. S/he had received his/her Torsemide 20mg on 01/23/25 and did not receive it again until 01/28/25.
- The facility was unable to produce physician orders for Resident 1’s Torsemide.
Based on facility reports and interviews, it was determined the facility failed to carry out medication and treatment orders as prescribed which is a violation of Oregon Administrative Rules.