Date: 1/14/2020
Report Number: 00066064-AP-047724
Allegation: Failed to provide oversight and monitoring of change of condition
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) by failing to provide the basic care or services necessary to maintain the health and safety of an adult, when that failure:(i) Results in physical harm, significant emotional harm, unreasonable discomfort, or serious loss of personal dignity to the adult; or (ii) Creates the risk of serious harm to the adult. AP did not respond to staff request for assistance when staff could not provide for the safety of AV.
Rule(s) Violated: 411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0030(1)(e)(I)
411-054-0040(1)(a) and (d)
Result: Substantiated
Findings: On or about January 13, 2020, the Alleged Victim (AV) experienced a change in condition. The facility clinical staff failed to assess, intervene, and monitor the change of condition, even though overnight staff complained they could not keep the AV safe. AV experienced confusion, falls and general agitation. AV was finally transported to the hospital at 4:30 am. During the hours of behaviors without intervention, AV was at risk of serious harm, as well as other residents of the facility. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse.
Sanction: ALFCP20-00506 $500.00 fine assessed