Violation Details: 00035508-AP-024984

Records Request Print
Date
6/11/2019
Report number
00035508-AP-024984
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) is care planned a high fall risk. On or about June 11, 2019, AV fell out of bed sustaining multiple injuries. Interventions as described in AV's care plan were not in place at the time of the fall. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) failed to follow AV's care plan, which is considered neglect of care and constitutes abuse. The facility failed to ensure AV's care plan was followed which is a violation of Oregon Administrative Rules.