Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00204246-AP-164700
Provider Information
Bonaventure of Albany Memory Care
420 GERI ST NW
Albany, OR 97321
- Provider ID
- 50R430
- Administrator
- Jessica Davenport
- Phone
- (541) 497-5600
- wellnessdirectoralb@livebsl.com
Violation Details
- Date
- 6/8/2022
- Report number
- 00204246-AP-164700
- 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 medications. On or about June 8, 2022, at approximately 0930 hours, Alleged Perpetrator 2 (AP2) accidentally administer to AV Witness 1’s (W1’s) medications which contained multiple hypertensive medications, medications for edema, blood thinning medication, thyroid medication for hypothyroidism along with other lesser vital medications. As a result, AV’s systolic blood pressure was 130 and after the medication error was low with a reading of 103, which required days of hospitalization for monitoring and treatment. The facility trained AP2 for three (3) days as a medication technician and on the 4th day, facility asked AP2 to pass medications, on his/her own because there were no other staff, at that time, to pass medications. Training records shows training occurred on June 3, 2022, but does not indicate additional training. AP2 did not feel confident and did not believe he/she have enough training but felt obligated to follow the direction of the facility request made by his/her superior. 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
- RCFCP23-00570 $375.00 fine assessed