Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00058768-AP-041813
Provider Information
The Butte
1250 SE ROBERTS AVE
Gresham, OR 97030
- Provider ID
- 50M092
- Administrator
- Ryan Callahan
- Phone
- (503) 667-5430
- rycallahan@sapphirehealthservices.com
Violation Details
- Date
- 9/17/2020
- Report number
- 00058768-AP-041813
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious 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
- Alleged Victim (AV) requires facility assistance with managing his/her medication. From approximately September 17, 2020 through September 29, 2020, AV was administered 5 mg of his/her blood thinning medication instead of the ordered 2mg. On or about September 30, 2020, AV's INR was checked and was abnormally high. AV was hospitalized from October 1, 2019 through October 8, 2019 for anemia due to acute blood loss related to his/her blood thinning medication. AV reported experiencing negative impact to his/her health due to the medication error. 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
- RCFCP21-01682 $500.00 fine assessed