Print Violation: CALMS - 00068442

Provider Information

Mountain Park Memory Care Community

13600 SE 122ND AVE
Clackamas, OR 97015

Date: 8/27/2024
Report number: CALMS - 00068442
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0055(1)
Findings: A review of Resident 1’s signed physician orders, dated 08/16/24, revealed an order for “MORPHINE (MSIR) 15 MG TABLET take 0.5 tablets by mouth 3 times daily as needed for pain (Additional ½ tab may be offered for pain 8/16-8/18).“ A review of Resident 1’s 08/01/24 – 08/31/24 MAR revealed the above order was not entered into the MAR. A review of “Suspected Abuse or Unexplained injury reporting form,” dated 08/30/24, revealed “on 8/27/2024 at 4pm MT gave [Resident 1] a PRN of Morphine because [s/he] said [s/he] was in pain. [S/He] has a PRN card for it. End date on the card was 8/18/24. The end date was unnoticed by the MT on shift.” During an interview, Staff 1 (Resident Services Manager) stated Resident 1’s PRN medication should have been added to the MAR, but was not and Resident 1 did not have an order for a PRN pain medication to be given on 08/27/24.