- Date
- 8/13/2025
- Report number
- CALMS - 00086873
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 08/18/25 and 08/20/25, the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed, and failed to provide written communication of a resident's change of condition, including any required interventions, to caregivers on each shift in accordance with OAR 411-054-0040 (1-2) was substantiated for 1 of 1 sampled resident. (# 1). Resident 1’s mental health and medication changes were not evaluated, and interventions were not communicated to caregivers on each shift. Resident 1 suffered a fall from a second story window resulting in serious injury.
Findings include but are not limited to: Resident 1 moved into the facility on 03/2024 with a diagnosis of major depressive disorder. S/He was admitted to hospice on 06/13/25. Resident 1’s service plan, dated 06/17/25, indicated “Staff should be aware of actions that may indicate increased mental health struggles and/or the need for support such as self-isolation or showing a lack of interest such as: refusing to eat, refusing to take medications or see family.” And noted Resident 1 had a history of hallucinations and delusions and had demonstrated “anxious/paranoid or suspicious behavior.” Staff were instructed to “reassure [him/her] [s/he] was safe and give [him/her] time to vent and express [his/herself].” On 06/13/25, Staff 5 completed a form titled Significant Change of Condition Comprehensive Assessment. There was no documented evidence interventions were made as a result of the assessment or communicated to staff. There was no documented evidence of interventions for staff on each shift to take or monitor in the event Resident 1 was experiencing suicidal ideations or hallucinations. Progress notes for Resident 1, dated 07/17/25 through 08/13/25, indicated:
- On 08/06/25, Resident 1 was suffering hallucinations, seeing children in his/her room;
- On 08/10/25, Resident 1 was experiencing hallucinations, thinking s/he was a fictional character;
- On 08/11/25, Resident was found on the floor of his/her apartment, confused, with unidentified pills in his/her hand, again experiencing hallucinations, that there was a man in his/her bathroom;
- On 08/12/25, Resident 1 “appears agitated, restless, and [sic] hallucinations;” and
- On 08/13/25, Resident 1 had hit a family member in the face with a metal water bottle, made comments about wanting “to be taken out of this world,” and staff had administered PRN Haloperidol and Olazepam. The 08/13/25 progress note also indicated on 08/11/25 Resident 1 had been combative with staff, hallucinating, and telling staff “everyone was trying to kill [him/her].”
- The progress note entries on 08/06/25, 08/10/25, 08/11/25, and 08/12/25 were documented as “outside provider notes.”
Resident 1’s physician orders, dated 07/17/25 through 08/12/25, indicated:
- On 07/17/25, Resident one was prescribed Haloperidol 5mg scheduled once a day, one hour before bedtime, for nighttime hallucinations;
- On 08/05/25, Haloperidol 2mg (hallucinations and agitation) every six hours PRN discontinued, Lorazepam 0.5mg (agitation and restlessness) every four hours as needed discontinued and Haloperidol 2mg every four hours PRN started, Lorazepam 1mg every four hours as needed started.
- On 08/11/25, the following medications were discontinued: Lantus SoloStar 100 units/mL (insulin) once daily at bedtime, Risperidone 1mg (hallucinations) twice daily, Carvedilol 6.25mg (hypertension) two times daily, Duloxetine 20mg (depression) two capsules twice a day, Furosemide 40mg (edema) once daily, and Gabapentin 100mg (neuropathy) twice a day;
- On 08/11/25 Resident 1 was prescribed Lorazepam 1 mg (sleep/hallucinations) once a day;
- On 08/12/25, the following medications were discontinued: Lorazepam 1mg every four hrs PRN, Lorazepam 1mg once a day, Dilaudid 2mg (pain management) every 0.5 tablet every two hours as needed, Dilaudid 2mg three times a day;
- On 08/12/25, the following medications were prescribed: Methadone Hydrochloride 0.25mL (pain management) every 12 hours as scheduled, Olanzapine 5mg 0.5 tablet. Notes indicated staff to use Haloperidol if Olanzapine was ineffective.
- There was no documented evidence Resident 1’s ongoing hallucinations or multiple medication changes were monitored, previous interventions for hallucinations had been used and/or were effective, or new actions or interventions were developed or communicated to staff.
An incident report, dated 08/15/25, indicated:
- Resident 1 had been administered PRN medication for hallucinations at 02:38 pm with ineffective results;
- Staff had noted the medications administered had been ineffective;
- At 05:08 pm Resident 1 had fallen from a second story window; and
- At the time s/he fell from the window s/he was hallucinating and stating someone was after her.
On 08/13/25 at approximately 5:08 pm, Staff 1 heard someone yelling for help. S/He found Resident 1 beneath an open second story window. Resident 1 was sent to the hospital and diagnosed with “multiple fractures.” Resident 1 died at the hospital on 08/14/25. On 08/18/25 at 12:35 pm, Staff 5 stated "I did a Change of Condition on 06/13/25 when [s/he] went on Hospice. I reviewed the Change of Condition on 06/18/25 and determined monthly reviews of the Change of Condition were appropriate." There was no documented evidence the RN had reviewed the change of condition since 06/18/25. The facility’s failure to evaluate the resident, refer to the facility nurse, document the change, update the service plan as needed, and provide written communication of required actions or interventions for caregivers on each shift was substantiated.
On 08/20/25 at 5:10 pm, the LCU team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 08/20/25 at 6:38 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The facility failed to assess, monitor, and intervene when Resident 1 experienced a significant change of condition. The facility's failure is a serious violation of Oregon Administrative Rules. Corrective Action taken on related allegation.