- Date
- 6/26/2025
- Report number
- CALMS - 00084996
- 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 07/24/25, the facility’s failure to carry out treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Compliance Specialist (CS) reviewed Resident’s 1’s (R1) service plans, progress notes, and Hospice RN charting orders, which indicated the following:
· R1 service plan dated 03/19/25 indicated Fall prevention, 1-person assist for all transfers, and 2-3 safety checks.
. Hospice Treatment Order/Interventions dated 06/24/25: indicated 15-minute checks, 0.5 morphine sulphate every 4 hrs. round the clock, vitals, please call with any questions or condition changes. 06/25/25: indicated discontinued all scheduled medication, the resident's breathing is labored, please call Hospice RN with any changes or concerns.
. Progress notes 06/25/25 indicated resident was very tired, refused medication, but did receive .25 morphine. Next note 06/26/25 6:56 am Resident passed, notified Hospice.
In an interview, Staff 4 stated the following:
-S/He was the MT on 06/26/25 assisting R1.
-S/He was not completing 15-minute or hourly safety checks on [R1].
-Stated s/he administered medication at 2 am and 4 am. [R1] was not responsive when administering medication.
-S/He was not documenting any changes or vitals for [R1]. When asked why they didn’t, she/he stated, “I don’t know”.
-S/He did not report to Hospice RN, ED, or call 911 with any changes in [R1's] condition or when she/he could not find a pulse. When asked why they didn’t, she/he stated, “I don’t know”.
In an interview with Staff 2 and Staff 3, they stated the following:
-The facility procedure was not to administer medication to a resident who was not alert and responsive.
-When a resident’s condition changes, especially if you can’t find a pulse or the pulse is weak, staff are to immediately notify the RN, ED, or call 911.
Findings were reviewed with and acknowledged by Staff 1 on 07/24/25. The facility’s failure to carry out medication and treatment orders as prescribed was substantiated which is a violation of Oregon Administrative Rules.