Print Violation: 00354863-AP-305179

Provider Information

Kelly Gardens Residential Care

813 NE KELLY AVE
Gresham, OR 97030

Date: 9/17/2024
Report number: 00354863-AP-305179
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: 411-054-0027(1)(g)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) is under the care of the facility and AV is care planned for pain medication management. On September 15, 2024, September 16, 2024, and September 17, 2024, AV suffered an increased in pain due to the facility not reordering AV's narcotic pain medication in a timely manner. Based on facility documentation and interviews, staff were pulling AV's narcotic pain medications from incorrect cards which caused staff to not accurately track when AV's narcotic pain medication needed to be reordered to ensure availability. The facility's failure to provide a safe medication administration system to ensure AV's narcotic pain medications were administered as ordered. The failure resulted in AV experiencing pain lasting more than 24 hours, causing unnecessary unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP25-00028 $1013.00 fine assessed