Print Violation: 00230745-AP-188660

Provider Information

Avamere at Chestnut Lane

1219 NE 6TH STREET
Gresham, OR 97030

Date: 11/7/2022
Report number: 00230745-AP-188660
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: On or about November 7, 2022, Alleged Perpetrator 2 (AP2) administered the wrong medication to Alleged Victim (AV) which resulted in AV going to the hospital for treatment. On the way to the hospital, AV required administration of a rescue medication as a result of AP2's medication error. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system for AV which resulted in unreasonable discomfort and hospitalization. The facility's failure is a violation of resident rights, is considered neglect of care which constitutes abuse.
Sanction: ALFCP23-00442 $1125.00 fine assessed