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Date
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2/15/2017
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Report Number
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ES179810
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Allegation
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Failed to adequately care plan related to falls
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Type
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Neglect
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Level
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2 - Minor harm or potential for moderate harm
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Description
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Resident #1 had five reported falls from 1/8/17 to 2/16/17 with three unwitnessed falls resulting in injury and hospital visits. Resident #1 was discharged from the hospital on 1/11/17 and was described as a high fall risk. The facility failed to update Resident #1's care plan regarding fall prevention. On 2/15/17 Resident #1 had an unwitnessed fall in his/her room resulting in cuts and abrasions. The facility's failure to implement appropriate fall interventions is a violation of the Oregon Administrative Rules, is considered neglect of care and constitutes abuse.
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Rule(s) Violated
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411-054-0027(1)(f) and (r)
411-054-0036(2)(g)
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Result
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Substantiated
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Findings
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COMPLAINANT STATEMENT: Unwitnessed fall by resident in RCF with injury. Facility failed to provide necessary mitigation for resident to avoid falling and/or devices which would prevent injury if a fall occurred.