Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00332053-AP-283276
Provider Information
Sherwood Pines Residential Care
87986 SHERWOOD ST
P.O. Box 1016
Veneta, OR 97487
- Provider ID
- 50M264
- Administrator
- Karensa Schill
- Phone
- (541) 935-0653
- kerensaschill@sherwoodpines.com
Violation Details
- Date
- 4/8/2024
- Report number
- 00332053-AP-283276
- 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: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0055(1)(a) and (f)
- Findings
- September 8, 2025, Substantive amendments to this First Amended Notice are identified: On or about April 11, 2024, Alleged Perpetrator 2 (AP2) irrigated Alleged Victim's (AV) catheter with a cleaning solution that is not intended for insertion into AV's body. Based on facility documentation, AP2 stated he/she had reservations about using a non-sterile solution in AV's irrigation, but trusted information given to him/her by Alleged Perpetrator 3 (AP3). AP2 was delegated by specialized staff for catheter care. AP2 had been instructed specifically by that staff person to go directly to delegating staff with questions related to AV's catheter. AP2 did not check AV's MAR for instructions on the catheter irrigation. Detailed information is given on the MAR, outlining very specific instructions for preparing the sterile solution to be used for this procedure. AP3 was not delegated for catheter irrigation, nor was AP3 in a role appropriate for asking procedural questions. AP2 failed to report to any appropriate staff the moment AV yelled out in pain. Per facility protocol, AP2 should have contacted AV's specialized provider and three different positions of specialized facility staff for further instructions. AP2 neglected AV by failing to follow doctor's orders, which resulted in unreasonable discomfort and increase in pain. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to ensure AV's medication treatment was properly administered as ordered and failed to provide appropriate follow-up care after the incident. Based on facility documentation and interviews, it was determined that the facility failed to promptly follow-up with retraining AP2 and AP2 continued to do AV's catheter irrigation for a couple of days after the incident before being removed from this task. As a direct result of this error, AV experienced a significant amount of pain for days after the incident, to a point that staff could not complete the irrigation as prescribed, and AV's urine was thick with debris/pink coloring. The facility's failure to both ensure staffed followed specific protocols for medication treatment administration before the incident and failure to provide an appropriate response after the incident caused AV pain and unreasonable discomfort lasting more than 24 hours, is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) allegedly neglected AV. An investigation determined no abuse occurred by AP3.
- Sanction
- RCFCP24-00841 $500.00 fine assessed