Print Violation: 00259126-AP-214593

Provider Information

Avamere at Bethany Assisted Living Facility

16360 NW AVAMERE CT
Portland, OR 97229

Date: 4/21/2023
Report number: 00259126-AP-214593
Type: Licensing Violation
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: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(a) and (f)
Findings: On or about April 21, 2023, Witness 3 (W3) administered the wrong medication to Alleged Victim (AV) which caused AV to experience unreasonable discomfort due to AV feeling shaky, sweaty, weak, and nauseous as a result of the medication error. AV was transported to hospital for evaluation. Based on facility documentation and interviews, Alleged Perpetrator 2 (AP2) was training W3 at time of incident and was expected to oversee medication pass. AP2 left W3 while in training and did not oversee the medication pass. AP2's actions is considered neglect of care which constitutes abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.