Clatsop Care Center

In the surveyor’s words

From the most serious findings on record at Clatsop Care Center, in the surveyor’s own words.

• Actual harm, isolatedF760Jul 18, 2024

  Based on interview and record review it was determined the facility failed to properly administer anticoagulant medication to 1 of 2 sampled residents (#2) reviewed for medications. As a result, Resident 2 was hospitalized and required Vitamin K infusion (used as reverse the effects of blood thinning medications). Findings include: Resident 2 was admitted to the facility in 5/2021, with diagnosis including paroxysmal atrial fibrillation (irregular heart beat caused by poor blood flow). Resident 2's 5/20/22 Care Plan noted the resident received Coumadin (an anticoagulant medication) related to atrial fibrillation. Resident 2's 5/2022 physician orders indicated Resident 2 was to be administered Coumadin 5 mg daily every Tuesday, Friday, and Sunday at 4:00 PM. […]

• Actual harm, isolatedF658Jun 14, 2023

  Based on interview and record review it was determined the facility failed to ensure nursing professional standards of practice were followed for 1 of 1 sampled resident (#33) reviewed for hospitalization . This resulted in Resident 33 being transported to the hospital and placed in the ICU on a ventilator. This also placed other residents at risk for hospitalization . Findings include: The Oregon Nurse Practice Act included the following: Oregon Administrative Rule [PHONE NUMBER] Scope of Practice Standards for Licensed Practical Nurses - Standards related to the LPN's responsibility for nursing practice. […]

• Actual harm, isolatedF684Jun 14, 2023

  Based on interview and record review it was determined the facility failed to follow physician's orders and the plan of care for 3 of 8 sampled residents (#s 16, 20 and 33) reviewed for hospitalization , dialysis and medications. This resulted in Resident 33 being transported to the hospital where the resident was placed in the ICU on a ventilator and died three days later. This also placed other residents at risk for hospitalization and unmet needs. Findings include: 1. Resident 33 was admitted to the facility in 2023 with diagnoses including hip fracture. The facility's Bowel Management Policy and Procedure dated ,d+[DATE] included the following interventions for when a resident did not have a bowel movement: - On day three administer Milk of Magnesia in the evening. […]

• Actual harm, isolatedF692Jun 14, 2023

  Based on interview and record review it was determined the facility failed to promptly intervene when a resident experienced severe weight loss for 1 of 3 sampled residents (#30) reviewed for nutrition. This resulted in an unplanned severe weight loss for Resident 30 and placed residents at risk for unplanned weight loss. Findings include: Resident 30 was admitted to the facility in 2023 with diagnoses including Multiple Sclerosis (disease of the brain and spinal cord). On 6/11/23 at 10:48 AM Witness 1 (Family) stated Resident 30 lost 17 pounds in about a month. Resident 30's diet order dated 5/4/23 included a general diet with regular texture and thin consistency (for fluids). […]

• Actual harm, isolatedF692May 28, 2021

  Based on observation, interview, and record review it was determined the facility failed to monitor weights for a resident identified at nutritional risk and failed to implement new interventions to prevent weight loss for 1 of 2 sampled residents (#17) reviewed for nutrition. This resulted in a severe unintended weight loss of 14% over two months. Findings include: Resident 17 was admitted in 12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] identified the resident to have mild cognitive impairment, several indicators of depression, but no appetite problems. The resident required extensive assistance from staff for most ADLs but only supervision for eating. Resident 17's admission weight was documented as 133 lbs. […]