Print Violation: 00111069-AP-085634

Provider Information

Sellwood Senior Living

8517 SE 17TH AVENUE
Portland, OR 97202

Date: 11/7/2020
Report number: 00111069-AP-085634
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: 411-054-0028(2)
External site: 411-054-0055(1)(a)
External site: 411-054-0070(1)
Findings: Alleged Victim (AV) relies on facility staff to administer his/her medications. On or about Alleged Perpetrator 2 (AP2) was assisting Alleged Perpetrator 3 (AP3) with passing medications. AP3 prepared a cup of medications and gave them to AP2 to administer to a resident. AP2 administered the medication to AV by mistake. AV was taken to the emergency room for observations and displayed no effects from the medication error. AP2's actions are considered neglect of care and constitutes abuse. Through the investigative process several medication technicians describe the day shift medication pass as a task that cannot be completed by one medication technician and this concern was brought up to the facility on multiple occasions. Additionally, the facility did not have a policy in place that did not permit medications to be prepared by one person and administered by another. 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: ALFCP21-01402 $188.00 fine assessed