- Date
- 8/29/2019
- Report number
- 00047143-AP-032906
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about August 29, 2019, Alleged Victim (AV) had a non-injury fall out of his/her wheelchair. An investigation determined that AV is care planned not to be left unattended in his/her wheelchair while in his/her room. Alleged Perpetrator 3 (AP3) was a new employee being mentored by Alleged Perpetrator 2 (AP2) on the day of the incident. AP2 failed to oversee that AP3 assisted AV with transfer from his his/her wheelchair after AP3 brought AV back into his/her room. AP2's failure to ensure AP3 followed AV's care plan is considered neglect of care which constitutes abuse. The allegation that AP3 failed to follow AV's care plan was investigated and determined no wrongdoing by AP3. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.