Print Violation: 00052702-AP-036674

Provider Information

Sweetbriar Villa

6135 E ST
Springfield, OR 97478

Date: 9/17/2019
Report number: 00052702-AP-036674
Type: Abuse: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation: Failed to administer medication as ordered
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) was placed on blood thinning medication for a secondary prevention of stroke. The medication was entered into the medication administration record incorrectly causing AV's medication not be passed on September 7, 2019 and September 14, 2019. AV suffered from a stroke on September 17, 2019, was sent to the hospital and passed away on September 30, 2019. Per AV's provider there is a possibility that the missed doses could have contributed to AV having a stroke event as the reported blood levels were already low to begin with and an additional day of missed dose possibly causing a delay in the medication effectiveness. The facility failed to administer the medication as ordered, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP20-00908 $15000.00 fine assessed