Print Violation: 00083622-AP-062299

Provider Information

Avamere at Sandy

17727 SE LANGENSAND RD
Sandy, OR 97055

Date: 5/13/2020
Report number: 00083622-AP-062299
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to intervene when resident's condition changed
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0040(1)(b) and (c)
External site: 411-054-0040(2)
Findings: On or about May 11, 2020, Alleged Victim (AV) was sent out and returned with medication changes that AV was placed on alert for. On or about May 12, 2020 at 6:30pm, AV reported a non-injury fall from his/her chair. Staff took AV's vitals signs after the fall which show AV's oxygen stats were at 66%. Staff took repeated AV's oxygen level at approxemetly 10:16pm which was 66% and at 10:25pm which was 64%. If a residents oxygen level is under 91% the facility calls 911. No call to 911, primary care physician or appropriate staff was noted, only family contact after the falls at 6:30pm. At approxemetly 1:30am on May 13, 2020, AV experienced a second fall. Staff was with AV from 3:00 am to 3:30am. At 4:30am on May 13, 2020, staff went to check on AV, AV was unresponsive and had passed away. The facility failed to address AV's change in oxygen levels which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP20-01027 $375.00 fine assessed