- Date
- 6/10/2024
- Report number
- OR0005120700
- 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 04/02/25, the facility's failure to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1) was substantiated. Findings include, but are not limited to: Compliance Specialist (CS) reviewed Resident 1's June 2024 MAR, progress notes, and physician orders which indicated the following:
- Order dated 06/09/24 for Carbidopa/Levo 25-250MG tab 1 tablet by mouth 3 times daily before breakfast, lunch, and before evening meal for Parkinson's.
- MAR indicated resident was to receive Carbidopa/Levo 25-100 MG 1 tablet by mouth before breakfast and lunch.
In an interview, Staff 2 was aware of the issues with Resident 1 not getting the correct medication dosage on 06/10/24. She/he stated the MT received one on one coaching at the time and MT no longer works at facility.
The facility's failure to carry out medication and treatment orders as prescribed is a violation of Oregon Administrative Rules.