Print Violation: 00407142-AP-358207

Provider Information

Mcloughlin Memory Care of Oregon

1145 MOLALLA AVENUE
Oregon City, OR 97045

Date: 6/11/2025
Report number: 00407142-AP-358207
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: 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: The Alleged Victim (AV) suffered a fractured ankle on June 7, 2025, which was causing AV increased pain. On or about June 9, 2025, due to increased pain, hospice increased AV's pain medication. Staff thought that hospice canceled AV's current medication and did not have the new order for AV's pain medication. When staff checked for the new order, later it was discovered that the fax machine had been unplugged, therefore, hospices new order could not get through. Hospice did not cancel the current order and staff could have given AV pain medication through the old medication order. AV went without pain medication for at least 5 hours, leaving AV in pain and unreasonable discomfort. Respondent failed to provide a safe medication administration system. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction: RCFCP26-00171 $1500.00 fine assessed