- Date
- 8/13/2025
- Report number
- CALMS - 00086877
- 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 site visits on 08/18/25 and 08/20/25, the facility’s failure to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055 (1) (f) was substantiated for 1 of 1 sampled resident(s). Findings include, but are not limited to: An unsigned physician order for Resident 1, faxed to the facility on 08/12/25, indicated to discontinue the following medications:
- Lorazepam 1 mg tablet every four hours as needed (anxiety, shortness of breath);
- Lorazepam 1 mg once daily (sleep, hallucinations);
- Dilaudid 2 mg tab as needed every two hours (pain management); and
- Dilaudid 2 mg tab three times daily for pain management.
The discontinue order was not signed by a Physician or prescriber. Resident 1’s MAR, dated 08/01/25 through 08/13/25, indicated the facility stopped administering the above medications at 4:00 am on 08/12/25. An incident report, dated 08/09/25, indicated “Resident received 2 doses of 5mg haloperidol one at approx. 1854 signed out at1959 and one at approx. 2103 due to duplicate orders at separate times.” In an interview on 08/18/25, Staff 5, stated "On 08/09/25, Resident 1 received two, 5 milligram doses of haloperidol, s/he was sedated due to the extra dose.” The facility’s failure to carry out medication and treatment orders as prescribed is a violation of Oregon Administrative Rules.