Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00364461-AP-314775
Provider Information
Curry Manor
1458 QUAIL LANE
Roseburg, OR 97470
- Provider ID
- 5MA024
- Administrator
- MARY PARKER
- Phone
- (541) 673-3999
- cparker@tierraseniorliving.com
Violation Details
- Date
- 11/5/2024
- Report number
- 00364461-AP-314775
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and(s)
External site: 411-054-0028
External site: 411-054-0036(2)(g)
External site: 411-054-0055(1)(a) and (b)
- Findings
- On or about November 5, 2024, Alleged Victim (AV) was found unresponsive in bed during morning rounds and confirmed deceased by emergency responders. Based on facility documentation and interviews, AV was admitted to the facility on November 4, 2024, at approximately 2:30pm. No prescribed medications or physician orders had been received for AV at time of admissions. Alleged Perpetrator 2 (AP2) administered a non-narcotic pain medication to AV without a physician's order. The evidence of the investigation supports that the facility failed to ensure safe medication administration practices at the time of AV's admission. AV had a documented allergy to acetaminophen, and no physician orders had been received. Despite AP2's medication technician competency checklist for not having required signatures ensuring AP2 was competent to administrator medication, AP2 was allowed to work in a position administering medications. The facility failed to confirm AP2 was authorized to perform administration or ensure that critical medical information was accessible, placing AV at serious risk of harm. Although AP2 had not received training on how to respond when MAR information was unavailable, AP2 proceeded without confirming AV's orders or allergy status. AP2's actions is considered a serious neglect of care which constitutes abuse. The facility is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his/her employment duties. The facility's failure to provide adequate and professional oversight of its medication administration system for a newly admitted residents is a serious violation of AV's resident rights which resulted in serious neglect of care outcome because no medications or physician orders were available at time of admissions. The facility's failure is a serious violation of AV's resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- RCFCP25-00740 $1500.00 fine assessed