Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00367765-AP-318066
Provider Information
Stephanie Gardens Residential Care
19751 SE STARK ST
Portland, OR 97233
- Provider ID
- 50R503
- Administrator
- Jason Wart
- Phone
- (971) 292-2265
- ed@stephanieresidential.com
Violation Details
- Date
- 11/19/2024
- Report number
- 00367765-AP-318066
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate 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: 411-054-0055(1)(a) and (f)
- Findings
- Alleged Victim (AV) is a resident of the facility who receives assistance with Activities of Daily Living, including medication administration. On or about November 19, 2024, Alleged Perpetrator 2 (AP2) was assisting AV with his/her medications. AP2 applied medication underneath AV's right eyelid. After AP2 applied AV's medication, AV noticed that AP2 incorrectly applied AV's topical skin medication instead of AV's eye medication. AV attempted to wipe away the topical skin medication and accidently got some of the medication into AV's eye. As a result of AP2's error, AV experienced a burning sensation and discomfort in AV's eye as a result of AP2's medication misadministration. Based on facility documentation and interviews, AP2 completed training for Administration of Eye/Drops/Ointments on November 12, 2024, and completed training for Medication Errors, and how to prevent errors on November 12, 2024. AP2's actions caused AV unreasonable discomfort which is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.