Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00273340-AP-228113
Provider Information
Bonaventure of Gresham Memory Care
22514 SE STARK STREET
Gresham, OR 97030
- Provider ID
- 50R442
- Administrator
- Toni Gossard
- Phone
- (503) 328-0010
- memorycaregre@livebsl.com
Violation Details
- Date
- 7/4/2023
- Report number
- 00273340-AP-228113
- 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
-
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 July 4, 2023, the facility did not have AVs prescribed (comfort medication) for end-of-life comfort. As a result, AV appeared to be in distress, and no staff were available to respond Witness 2’s (W2) calls for staff assistance. A facility janitor responded and subsequently notified staff in another area of the facility. Staff believed that AV’s comfort medication order had been discontinued on or about June 28, 2023, however, following this incident, staff were told that AV’s comfort medication was located at the facility in a drawer. AV was conscious at the time, but AV couldn’t breathe, and he/she was vomiting and bleeding through his/her nose. W2 asked the facility staff if they could call EMS and the facility staff declined and stated that AV was on hospice and cannot be taken to the hospital. AV passed away on July 4, 2023, after AV experienced a great deal of discomfort for several hours. On or about July 3, 2023, staff at the facility noticed the facility had taken the comfort medication off the order list. The medication was reinstated and was put back on. None of the comfort medication orders were ever expired or canceled by hospice. On or about July 7, 2023, staff told W2 that there was comfort medication available at the time of AV’s death and showed pictures of it that were taken on June 30, 2023. The facility failed to provide a safe medication administration system for AV, leading to AV to experience a pain and discomfort, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- RCFCP23-01446 $500.00 fine assessed