Print Violation: 00093154-AP-083486

Provider Information

Mcloughlin Place Senior Living

1153 MOLALLA AVE
Oregon City, OR 97045

Date: 7/15/2020
Report number: 00093154-AP-083486
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) relies on the facility to administer his/her medication. On or about July 2, 2020, the facility received hospice orders to administer 100 unit/ml NPH insulin/12 units per day and Lispro 4 units twice a day. During the time period of July 2, 2020 through July 11, 2020, AV had nine (9) CBG values ranging from 363 to 479 which is over the 350 limit. Facility staff had reported to hospice that AV’s CBG was 454 on or about July 8, 2020 due to AV’s NPH insulin not being administered. 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: ALFCP21-03300 $500.00 fine assessed