Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00352383-AP-302667
Provider Information
Oswego Grove
4550 SW CARMAN DRIVE
Lake Oswego, OR 97035
- Provider ID
- 50R336
- Administrator
- Aurora Beiser
- Phone
- (503) 675-6055
- abeiser@avamere.com
Violation Details
- Date
- 9/2/2024
- Report number
- 00352383-AP-302667
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
- Findings
- The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. On or about September 2, 2024, AV suffered an unwitnessed fall. AV was found by staff sitting on the floor in his/her apartment by the bed. AV was gripping his/her left arm and verbalized he/she was in pain. AV was unable to move left arm. AV was transferred to the hospital and was diagnosed with a fractured left humerus. AV's injury was determined to be non-operable, and AV was discharged with a new narcotic pain medication prescription to wear a sling with instructions to follow-up with an Orthopedic doctor. Based on facility documentation and interviews, AV has a fall history which includes a history of falling out of bed. At time of incident, AV's room was dark due to a broken lamp and AV could not see. AV's locks on wheelchair were not working at time of incident and the only intervention for fall prevention was use of fall mat. An investigation determined the facility failed to implement sufficient fall interventions to mitigate AV's fall risk. The facility's failure to properly care plan for AV's fall risk caused unreasonable discomfort and severe pain lasting more than 24 hours which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00097 $2500.00 fine assessed