Print Violation: 00181426-AP-144258

Provider Information

Hawthorne Gardens Memory Care Community

2828 SE TAYLOR ST
Portland, OR 97214

Date: 1/28/2022
Report number: 00181426-AP-144258
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) relies on the facility for a safe environment. AV has history of behavioral changes when s/he misses a dose of h/h antipsychotic medications. On or about January 22, 2022, and January 23, 2022, AV did not receive h/h antipsychotic medication due to the facility not having the medication in stock, resulting in escalated behaviors on January 23, 2022, and January 24, 2022. AV has a history of falls. On or about January 25, 2022, AV was heard yelling in pain, and found in bed with a reopened skin tear on h/h arm. PRN medications were not effective, and AV was sent to the ER, where AV was diagnosed with bruising, on h/h right elbow and a right hip fracture. The Facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP23-00320 $1125.00 fine assessed