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F0658
D

LPN Absence Results in Missed Medications and Treatments

Portland, Oregon Survey Completed on 06-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff 17, a former agency LPN, failed to adhere to professional standards for medication management and oversight of assigned residents during a night shift. According to interviews and record reviews, Staff 17 was absent from the facility for most of her shift, having slept in her car in the facility parking lot. As a result, seven residents missed their ordered medications and did not receive PRN medications or treatments as required. Staff 17 was found asleep in her car near the end of the shift and indicated she could not finish her duties. Other staff confirmed her absence and the resulting missed medication administration. The Director of Nursing Services (DNS) and other staff verified that Staff 17 was not present to fulfill her responsibilities, which included administering medications and treatments as ordered by providers. Attempts to contact Staff 17 after the incident were unsuccessful, as provided phone numbers were either disconnected or not answered. The investigation confirmed that the lack of licensed nurse oversight during the shift led to unmet medical needs for the affected residents.

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