Print Violation: 00274388-AP-229019

Provider Information

Avamere at Chestnut Lane

1219 NE 6TH STREET
Gresham, OR 97030

Date: 7/18/2023
Report number: 00274388-AP-229019
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: 411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. On July 18, 2023, the facility identified an error with AV's antidepressant medication in which AV had been administered twice the daily dosage than what was prescribed since July 7, 2023. Based on interviews and facility documentation, the medication error caused AV to experience drowsiness and AV had several falls between July 11, 2023 and July 13, 2023, resulting in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP23-00669 $375.00 fine assessed