- Date
- 10/8/2025
- Report number
- CALMS - 00096733
- 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 October 8, 2025, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Resident 1 was not administered his/her mood stabilization medication for approximately one month. Resident 1 experienced increased agitation. Findings include, but are not limited to:
Service plan dated July 10, 2025, indicated:
- Diagnosis of post-traumatic stress disorder, psychotic disturbance, mood disturbance and anxiety; and
- Required staff assistance with all medication orders and administration
Physician orders dated April 15, 2025, indicated:
- Olanzapine, 5mg tablet every day at bedtime for steady mood
Interview Staff 2:
- Med tech staff discovered the medication was gone but did not reorder the medication nor did they document a conversation with the pharmacy regarding the refill request.
- Medication Administration Record (MAR) dated August 2025, indicated s/he had not been administered his/her Olanzapine 25 times, with notes that said the medication was unavailable.
Progress notes indicated:
- On August 31, 2025, Resident 1’s irritation with staff had increased over the last week with “today being the worst”;
- On September 1, 2025, Staff 2 was informed that Resident 1 had not received Olanzapine for two weeks. Staff 3(RCC) stated a priority refill of Olanzapine was requested and it will be administered to Resident 1 in the evening on 09/01/25; and
- On September 3, 2025, staff reported Resident 1's Olanzapine was not reordered because the prescription bottle was thrown away and staff did not have the prescription number to order a refill.
There was no documented evidence the facility had attempted to contact Resident 1's pharmacy to request a refill for Olanzapine in 08/2025. The facility's failure to carry out medication and treatment orders is a violation of Oregon Administrative Rules.