Date: 8/12/2019
Report Number: 00044657-AP-031253
Allegation: Failed to properly plan care
Type: Neglect
Level: 2 - Minor harm or potential for moderate harm
Description: AP neglected AV as defined in OAR 411-020-0002(1)(b)(A)(i)(ii) by failing to ensure that AV had the basic care and supervision needed to keep AV safe from harm and injury.
Rule(s) Violated: 411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Result: Substantiated
Findings: Alleged Victim (AV) has a known history of being aggressive and combative with staff. On or about August 11, 2019, AV wandered into another resident's room without his/her walker. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) tried to redirect AV away from the room. AV started to bite and was being physically combative towards AP2 and AP3. On August 12, 2019, staff noticed AV had bruises on both his/her wrist. No other incident noted before the incident on August 11, 2019 and no one noticed or noted any bruises on AV's wrist before the altercation with staff on August 11, 2019. AP2 and AP3 both stated they were trained on how to handle residents with dementia and behaviors as well as abuse prevention. AP2 and AP3's actions are considered physical abuse. The facility failed to care plan and give staff direction on how to handle AV when he/she is being aggressive, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP20-00955 $500.00 fine assessed