Print Violation: 00342445-AP-293055

Provider Information

Kinsington Place

827 SW KINSINGTON COURT
Grants Pass, OR 97526

Date: 6/18/2024
Report number: 00342445-AP-293055
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)(s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: The Alleged Victim (AV) had a medication change on or about June 19, 2024. AV's medication had changed from 40 mg once per day to 40 mg twice per day. Facility staff thought they had faxed the order to the pharmacy, however, the fax went to AV's physician instead. It was not discovered that AV was not receiving his/her medication until staff noticed that AV had gained 15 lbs in one week. AV missed his/her medication from June 19, 2024 until June 26, 2024. On or about June 26, 2024, AV was transferred to the hospital with shortness of breath. The facility's failure to provide a safe medication administration system and provide AV's medication as ordered, placed AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP24-01266 $500.00 fine assessed