Print Violation: 00059301-AP-042185

Provider Information

Deerfield Village Assisted Living

5770 SE KELLOGG CREEK DR
Milwaukie, OR 97222

Date: 11/22/2019
Report number: 00059301-AP-042185
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to administer ordered medication
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: The facility failed to provide a safe medication administration system. Alleged Victim’s (AV) diuretic medication dosage was to be increased for three days and then was to resume at the previous dosage. On or about November 12, 2019, AV’s previous diuretic medication dosage was not resumed but instead was deleted from the Medication Administration Record, resulting in AV not receiving the diuretic medication for approximately seven days. During that time, AV complained of an increase in breathing problems, placing AV at risk for serious harm. The facility did not provide oversight of the physician orders and the error was not discovered until approximately November 19, 2019. AV’s diuretic medication was restarted on November 20, 2019 and AV passed on November 22, 2019. The facility’s failure is a violation of resident rights is considered neglect of care and constitutes abuse.
Sanction: ALFCP20-00324 $500.00 fine assessed