Print Violation: 00086785-AP-065029

Provider Information

Powell Valley Assisted Living Community

4001 SE 182ND AVE
Gresham, OR 97030

Date: 6/4/2020
Report number: 00086785-AP-065029
Type: Licensing Violation
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: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(a)
Findings: On or about June 4, 2020, Alleged Perpetrator 2 (AP2) was administering morning medications to facility residents. Prior to administering AV's medications AP2 placed AV's medications in a medication cup and placed the cup in his/her pocket. AP2 had already placed the medication cup for another resident in the same pocket, after that resident had refused his/her medication. AP2 entered AV's room and administered the other resident's medications to AV. AP2 realized the error immediately after AV consumed the medications and notified other staff and facility management. AV's blood pressure was low so he/she was sent out to the hospital for evaluation and later admitted and treated for abnormal hear rhythm and low blood pressure. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to protect AV from a facility staffs actions which is a violation of Oregon Administrative Rules.