Print Violation: 00069816-AP-050814

Provider Information

Avamere at Newberg

730 FOOTHILLS DRIVE
Newberg, OR 97132

Date: 1/16/2020
Report number: 00069816-AP-050814
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to administer medication as ordered
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(a) and (f)
Findings: The facility has a triple check system used to process new medications orders to ensure accuracy. On or about January 16, 2020, the facility received a new order to increase Alleged Victim's (AV's) blood thinning medication. Alleged Perpetrator 2 (AP2) entered the medication into the medication administration record with the incorrect dosing. AV received the wrong dosage from approximately January 16th through January 18, 2020, causing AV's INR to be out of therapeutic range. AP2 failed to follow the facility's established procedure to submit the changes for review for the second and third check causing AV to be at risk for significant harm, which is considered neglect and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.