Print Violation: 00357371-AP-307688

Provider Information

Pacific Grove Memory Care

3334 22ND AVE
Forest Grove, OR 97116

Date: 9/27/2024
Report number: 00357371-AP-307688
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to administer medication as ordered
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: 411-054-0030(1)(f)
External site: 411-054-0036(2)(g)
External site: 411-054-0055(1)(a) and (b)
Findings: The facility is responsible for administering Alleged Victim's (AV's) medications. On or about September 27, 2024, at around 2PM Alleged Perpetrator #2 (AP2) administered AV 40mg of narcotic medication instead of the prescribed 10mg dose. AV was aware there were four pills instead of one but did not alert anyone at the time. The facility was not aware of the medication error until the following day when AV alerted staff to it. AV refused to go to the hospital. AP2 has been trained by the facility in medication administration. AP2 has been disciplined for a medication error previously. AV had no negative outcome. The facility failed to provide a safe medication administration system and administer medication as ordered which is a violation of Oregon Administrative Rules.