Date: 7/5/2019
Report Number: 00038619AP-027175
Allegation: Failed to provide safe environment
Type: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Description: Between June 24, 2019 and July 5, 2019, Alleged Victim (AV) experienced three (3) falls which caused AV unreasonable discomfort. On AV's second fall, the facility did not have AV's Hoyer lift sling available to assist Emergency Medical Services (EMS) with transferring AV safely from the floor and it was determined by EMS that AV's wheelchair was not in working order because it could not be reclined which put AV at risk for slipping out of his/her wheelchair. On AV's third fall, EMS could not transfer AV from wheelchair to stretcher due to battery on hoyer lift being dead. AV, EMS, and facility staff had to wait until battery could be replaced. When EMS was able to assist in transferring AV from wheelchair to stretcher, EMS and facility staff discovered AV was suffering from severe bed sores to his/her lower extremities and buttocks. AV was then transferred to hospital for treatment. The facility failed to provide a safe environment for AV which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Rule(s) Violated: 411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0030(1)(d)
411-054-0036(2)(g)
411-054-0040(1)(a) and (d)
Result: Substantiated
Findings: The facility neglected AV as defined in OAR0200002(1)(b)(A)(ii) by failing to provide basic care or services to maintain the health and safety of AV which resulted in AV being hospitalized for rectal bleeding and bed sores.
Sanction: RCFCP19-917 $2500.00 fine assessed