Print Violation: 00354050-AP-304382

Provider Information

Pacific Grove Memory Care

3334 22ND AVE
Forest Grove, OR 97116

Date: 8/28/2024
Report number: 00354050-AP-304382
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to have medication available
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: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: On or about September 11, 2024, an audit was conducted by a facility nurse at which point it was discovered that AV missed medications that had been ordered by the ER on August 28, 2024. On or about August 28, 2024, AV was seen in the ER for shortness of breath and sent home with 2 different prescriptions for exacerbation. Upon return the same day, Witness 3 (W3) sent the after-visit summary noting new medications to the pharmacy via fax. On or about August 29, 2024, the pharmacy responded noting that the pharmacy could not dispense the medications because the faxed orders were unsigned. AV did not get the new medication until September 6, 2024 when AV's PCP provided an order during AV's follow up appointment. The facility failed to provide a safe medication administration system and administer medication as ordered which is a violation of Oregon Administrative Rules.