Print Violation: 00316843-AP-268912

Provider Information

Pacific Grove Memory Care

3334 22ND AVE
Forest Grove, OR 97116

Date: 3/4/2024
Report number: 00316843-AP-268912
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: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0030(1)(f)
External site: 411-054-0055(1)(a) and (f)
Findings: On or about March 04, 2024 Witness 2 (W2) administered AV's initial dose of 19 units of insulin and confirmed it on the MAR. Alleged Perpetrator 2 (AP2) was covering the medication cart and as AP2 was going through medications, AV’s insulin showed as needing to be administered. AV’s insulin was decreased from 19 units to 10 units per doctor order. AP2 went into the medication system and changed the unit amounts and also administered AV [an additional] 10 units of insulin. Facility RN discovered that a medication technician had already administered insulin to AV prior to AP2. AV was checked-on by facility staff and AV’s CBG was rapidly dropping due to receiving an extra dose of insulin. Emergency services were contacted and AV was transported to the hospital. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP24-00997 $375.00 fine assessed