Print Violation: 00326231-AP-277666

Provider Information

Churchill Retirement Assisted Living

3800 WESTLEIGH ST.
Eugene, OR 97405

Date: 11/21/2023
Report number: 00326231-AP-277666
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: 411-054-0055(1)(a) and (f)
Findings: The facility is responsible for storing and administering all of Alleged Victim's (AV) prescribed medications. In November 2023, one of AV's medications to treat a his/her medical condition was placed on hold by facility staff without a verifiable doctor's order. Based on facility documentation and interviews, the hold erroneously remained in place until audits were done in April 2024. AV did not experience any physical negative effects due to missing significant doses of this medication. The facility failed to provide a safe medication administration system by not having proper protocol in place for following up on medications that have been placed on hold, and this error could have been reasonably preventable. AV had still been taking a secondary medication to treat his/her medical condition until April 2024. The facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.