Date: 9/29/2016
Report Number: BH167866
Allegation: Failed to address resident's behavior
Type: Neglect
Level: 3 - Moderate harm or potential for serious harm
Description: On or about September 29, 2016 RV1 was observed fondling RV2's breast. W2 had observed RV1 leaving RV'1 room, but was unaware RV1 was to have supervision when out of RV's room due to a previous resident to resident sexual contact that occurred 09/24/2016. W2 had gone to answer call lights after observing RV1 leave RV's room and came back to find RV1 fondling RV2. W2 took RV1 down the hallway, answered call lights and returned to find RV1 next to RV2, but not touching RV2's breast; RV1 was redirected to RV's room. Staff including W2 report logging into their assigned resident's Kardex to find care plan changes. W2 was not assigned to RV1; W7 was assigned to RV1. W7 reported logging into RV1's Kardex, but was not aware RV1 required supervision when out of RV1's room. W7 reported at times the service plan is not immediately available in the Kardex. The facility failed to ensure all staff were aware of RV1's care plan changes resulting in RV1 sexually abusing RV2 and placing all residents at risk for harm. The facility failure constitutes neglect and abuse. Oregon Administrative Rule violations occurred.
Rule(s) Violated: 411-085-0360(1)
411-086-0060(2)(h)
411-086-0140(2)(a) and (b)(B) and (C)
Result: Substantiated
Findings: Facility failed to provide a safe environment.
Sanction: NFCP16-131 $300.00 fine assessed