Print Violation: 00260173-AP-215349

Provider Information

Bonaventure of Tigard Assisted Living

15000 SW HALL BLVD
Tigard, OR 97224

Date: 2/6/2023
Report number: 00260173-AP-215349
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 medication. On or about February 6, 2023, during the evening medication pass, AV was given an incorrect dosage of insulin (23 units), when their order for evening insulin was three (3) units of insulin. As a result for AV receiving an incorrect dose of insulin, AV sustained an adverse reaction which required immediate medical attention and AV being sent to the hospital. Alleged Perpetrator 2 (AP2) was asked to pass medication by the facility as they were short staffed in the evening, but AP2 was not fully trained by the facility as a medication technician until March 6, 2023. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: ALFCP23-00611 $250.00 fine assessed