- Date
- 9/10/2025
- Report number
- CALMS - 00096990
- 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 Licensing Complaint Unit (LCU) site visit on 12/18/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled
residents (#1). Findings include, but are not limited to:
Resident 1’s Physician Orders dated 08/18/25 indicated the following:
· Furosemide: take 1 tablet (20 mg) by mouth daily;
· Ipratropium-albuterol: take 3mLs by nebulization 4 times daily; and
· Haloperidol: take 75mL by mouth every 8 hours.
Resident 1’s Medication Administration Records (MARs) dated 08/01/25 through 09/15/25 indicated the following:
· Furosemide was not administered due to being unavailable from 08/12/25 through 08/18/25;
· Iprart/Albut .5-2.5mg was not administered due to being unavailable on 08/18/25 at 12:00 pm,
4:00 pm, and 8:00 pm; and on 08/19/25 at 8:00 am and 12:00pm; and
· Haloperidol was blank on the MAR on 09/10/25 at 1:00 pm.
Resident 1’s Progress Notes dated 08/10/25 through 09/15/25 indicated the following:
· On 08/19/25, resident was placed on alert charting for missed Furosemide, with the outcome being increased Shortness of Breath; and
· On 09/12/25, resident was placed on alert charting for missed Haloperidol on 09/10/25, with the outcome being restlessness and agitation.
Staff 1 (Executive Director) indicated the following:
· Furosemide had been ordered and was in the facility during the alleged time period, but had been placed in the incorrect location and had not been administered for several days as a result;
· It was discovered that the resident was not receiving Furosemide when they started exhibiting symptoms;
· The nebulizer treatments had been missed due to having run out on 08/18/25;
· Staff 1 had witnessed a med tech bringing Haloperidol to Resident 1 late on 09/10/25, but the med tech had not filled out the MAR; and
· The agency med tech on 09/10/25 did not have a key to the med cart for part of their shift. Resident 1 was no longer in the facility and was unavailable to be interviewed.
The facility’s failure to carry out medication and treatment orders is a violation of Oregon Administrative Rules..