Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00053545-AP-037372
Provider Information
Avamere Living at Newberg
730 FOOTHILLS DRIVE
Newberg, OR 97132
- Provider ID
- 70M208
- Administrator
- Kelci Mauser
- Phone
- (503) 554-0767
- kmauser@avamerecommunities.com
Violation Details
- Date
- 10/8/2019
- Report number
- 00053545-AP-037372
- Type
- Abuse: Neglect
- 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: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
- Findings
- The facility has an established triple check policy that calls for the medication technician who receives the order to update the medication administration record and verify it has been entered in correctly. A second verification is completed by a medication technician on the next shift. The third verification is completed by the facility nurse on there next shift. There is no time-frame outlined for the third check. On or about October 8, 2019, Alleged Victim's (AV's) blood thinning medication was lowered as a results of his/her lab work. Alleged Perpetrator 6 (AP6) was providing step-by-step training to a new medication technician on updating the medication administration record with the new order. The update failed due to the trainee's processing, and AP6 did not catch the error, resulting in the MAR not being updated with the new order. AP6 conducted the second part of the facility's established triple-check process. AP6 did not visually confirm that the MAR had been updated and so did not catch the error. As a result, AV was given a higher dose of blood thinner three time putting AV at risk for serious harm. The error wasn't caught until the third check was completed on October 11, 2019. AP4 and the facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP20-00554 $375.00 fine assessed